Every finding on record at Thomson-Hood Veterans Center

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents receiving respiratory care were provided services in accordance with physician orders for 1 of 2 residents reviewed for respiratory care, Resident (R) 144. Observation on 05/04/2026, 05/05/2026, and 05/06/2026 revealed R144 was receiving oxygen via nasal cannula at five liters per minute (LPM) instead of the physician ordered four LPM. This failure had the potential to place the resident at risk for complications related to improper oxygen administration.The findings include:Review of the facility's policy titled, Oxygen Monitoring/Changing of O2 Tanks, revised on 06/26/2024, revealed it stated, Residents who have chronic or acute symptoms of hypoxemia or hypoxia, i.e. shortness of breath or who are experiencing respiratory distress will be provided oxygen therapy as ordered by their Medical Provider. The policy further revealed, The oxygen tubing will be changed every week or when soiled with the tubing dated and initialed by nursing staff. Continued review revealed, If a humidifier is used it will be changed when empty or weekly, whichever comes first and labeled with resident's name, date opened and liters/minute. Review of R144's Face Sheet revealed the facility admitted the resident on 09/04/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and ischemic cardiomyopathy. Review of R144's Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/11/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Review of R144's Care Plan, dated 09/04/2025, revealed an intervention to administer oxygen therapy as ordered by the physician.Review of R144's Physician Orders, dated 09/04/2025, revealed an order for oxygen administration at four LPM via nasal cannula. Observation on 05/04/2026 at 10:26 AM revealed R144 receiving oxygen at five LPM via nasal cannula. The oxygen tubing was not labeled or dated, and the humidification bottle was also not labeled or dated. Observation on 05/05/2026 at 10:28 AM revealed R144 receiving oxygen at five LPM via nasal cannula. The oxygen tubing was not labeled or dated, and the humidification bottle was also not labeled or dated. Observation on 05/06/2026 at 10:25 AM revealed R144 receiving oxygen at five LPM via nasal cannula. The oxygen tubing was not labeled or dated, and the humidification bottle was also not labeled or dated and was empty. In an interview on 05/06/2026 at 10:28 AM with Licensed Practical Nurse (LPN) 3, she stated nursing staff was responsible for checking and changing oxygen humidification and tubing. She stated both were to be changed weekly or as needed, whichever occurred first and were to be labeled. LPN3 stated nursing staff verified residents' oxygen requirements by reviewing the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) in the medical record. When asked what R144's oxygen should be set at, LPN3 stated, Three liters. Review of MAR/TAR documentation revealed an active physician order for oxygen at four LPM. LPN3 was then asked to verify the oxygen regulator setting for R144, which was observed to be set at five LPM. In an interview on 05/06/2026 at 10:49 AM with the Unit Manager (UM) of the Roosevelt Unit, she stated nursing staff was to check residents' oxygen, including tubing and humidification, every shift. The UM stated nursing staff was expected to follow physician's orders concerning medication administration. The UM stated it was important to ensure that the correct amount of oxygen was given to residents. In an interview on 05/06/2026 at 1:35 PM with the Director of Nursing (DON), she stated staff was expected to follow physician's orders, particularly those related to oxygen administration. She stated it was important to follow physician's orders to ensure residents were not over-oxygenated or under-oxygenated and to maintain resident safety and proper care. In an interview on 05/07/2026 at 10:18 AM with the Administrator, he stated it was his expectation staff read and followed all physician's orders, including oxygen administration. He stated, It is important to maintain the health of the resident.

Based on observation, interview, review of the Dome lid manufacturer's webpage, review of the United States Department of Agriculture (USDA) guidance webpage, and review of the facility's documents, the facility failed to provide residents with palatable foods and deliver meals in a timely manner to 1 of 1 resident units sampled for food service, the [NAME] Unit. Observation of the breakfast meal on 03/26/2025 revealed food was not served timely to the resident rooms on the [NAME] Unit. The breakfast test tray on 03/26/2025 revealed hot foods were not palatable and measured 90 degrees Fahrenheit (F) to 110 degrees F. In interviews with residents on the [NAME] Unit, they reported receiving cold and unpalatable food, and the times for meal service varied daily. The findings include: Review of the United States Department of Agriculture (USDA) guidance webpage at https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation, not dated, revealed to hold hot foods at 140 degrees F. Per the guidance, bacteria grew most rapidly in the range of temperatures between 40 degrees F and 140 degrees F, with the bacteria doubling in number in as little as 20 minutes. The guidance stated this range of temperatures was often called the Danger Zone, and if the temperature was above 90 degrees F, food should not be left out more than one hour. Review of the Dome lid manufacturer webpage at https://www.cambro.com/Products/meal-service/healthcare/camduction-complete-heat-system/, undated, revealed a heated base, combined with a properly heated plate, covered with an insulated dome would maintain hot foods at safe temperatures of 140 degrees F or higher for 60 minutes. This offered a convenient, consistent solution for transporting and delivering meals at the temperature they were plated. Review of the facility's document Facility Mealtimes, not dated, revealed the breakfast tray line began at 6:45 AM, and the breakfast tray carts on the [NAME] Unit were delivered at 8:30 AM; the lunch tray line began at 10:45 AM, and the lunch tray carts on the [NAME] Unit were delivered at 12:30 PM; and the dinner tray line began at 4:45 PM, and the dinner tray carts on the [NAME] Unit were delivered at 6:30 PM. Review of the facility's form Test Tray, dated 12/12/2024 at 6:00 PM, for dinner on the [NAME] Unit, revealed hamburger at 110 degrees F; green beans at 130 degrees F; baked potato at 160 degrees F; spice cake at 40 degrees F; milk at 40 degrees F; and juice at 38 degrees F. Review of the comment for the test tray revealed it appeared good, tasted well, and was up to temperature at the time of service on the [NAME] Unit. The listed target time for hot foods was 110 degrees F. Review of the facility's form Wednesday Day 4 Breakfast, dated 03/26/2025, revealed the tray line start time was 6:50 AM, and the end time was 8:30 AM. The form stated for bacon, the starting temperature was 170 degrees F, and the ending temperature was 146 degrees F; for sausage patties, the starting temperature was 170 degrees F, and the ending temperature was 150 degrees F; for fried egg, the temperature was 168 degrees F with no ending temperature documented; for western scrambled egg, the starting temperature was 170 degrees F with no ending temperature documented; for hot oatmeal, the starting temperature was 180 degrees F with no ending temperature documented; and for country gravy, the starting temperature was 180 degrees F with no ending temperature documented. Observation of the short [NAME] Unit enclosed resident tray cart on 03/26/2025 at 8:23 AM revealed it was located in the hallway in front of the resident tray line. The tall enclosed resident tray cart for the [NAME] Unit was filled and taken with the short enclosed tray cart to the [NAME] Unit at 8:37 AM. The dining room residents were served first, and then both tray carts were taken to the residents on the [NAME] Unit at 9:02 AM, with the final tray served at 9:11 AM. Observation of the test tray on 03/26/2025 at 8:35 AM on the [NAME] Unit with the Prep Center Coordinator revealed the toast was warm, soft, and bendable; the fried egg was at 108 degrees F; the scrambled egg was at 118 degrees F; sausage was at 105 degrees F; bacon was warm and crisp; oatmeal was at 110 degrees F; gravy was at 90 degrees F, and the biscuit was at 98 degrees F. The cold food of milk was at 42 degrees F, and orange juice was at 45 degrees F. In an interview with the Prep Center Coordinator on 03/24/2025 at 4:45 PM and on 03/26/2025 at 8:37 AM, she stated the staff placed the food in the steam table at 3:30 PM, and the dinner was served at 4:45 PM. She stated she assisted with test trays and checked temperatures only. She stated she did not taste the food on the test tray. In an interview with [NAME] 2 who had the position title of [NAME] One on 03/26/2025 at 8:31 AM, he stated the breakfast tray line for the small cart for the [NAME] Unit was set-up from 6:15 AM to 6:30 AM. In an interview with Resident (R) 79 on 03/24/2025 at 3:45 PM, who resided on the [NAME] Unit, he stated eggs were all they had at breakfast every morning. He stated they needed to have something other than eggs. In an interview with R120 on 03/25/2025 at 2:10 PM, who resided on the [NAME] Unit, he stated the food was average. He stated the meat was overcooked, the fried egg was rubbery, and the sausage was overcooked. He stated the longer he waited to be served, the food became cold and the vegetables became watered down. He stated he survived on the canned fruit served with every meal. In an interview with R106 on 03/25/2025 at 4:03 PM, who resided on the [NAME] Unit, he stated the food was not well prepared. He stated he received food last, which was cold or at room temperature. He stated the food was not appetizing, and the meat was tough and chewy because it had been prepared too fast and at a high temperature. He stated the meat always had a sauce or some type of covering over it. He stated the menu had bazaar foods, such as a lot of chicken and was covered with sauce. He stated the mealtimes were always changing and got later and later at night. He stated he received supper on 03/24/2025 at 7:00 PM and not 6:30 PM, referring to the time listed and posted in his room as 6:30 PM. He stated the time posted near the dining room was 6:30 PM for dinner, but they do not seem to have enough staff, with no cooks. In an interview with R47 on 03/25/2025 at 10:20 AM, who resided on the [NAME] Unit, he stated the food was slop, and the grilled cheese sandwich was just two pieces of cheese placed on bread. He stated he only ate breakfast, i.e. eggs, bacon, or sausage. He stated he had frozen meals for lunch and dinner because the food was horrible. In an interview with the Food Service Operations Manager on 03/26/2025 at 9:08 AM, she stated she liked food to be held at 140 degrees F, but did not have a point of service temperature. She stated she had not completed a test tray since 12/12/2024. She stated dietary staff went to lunch break prior to the supper meal service and placed food onto the tray line at 3:30 PM. She stated placing food early onto the steam table had the potential for the vegetables to become mushy and the meat to overcook and become tough. She stated her expectations were for the meat to be tender and the vegetables to be crisp. In an interview with the Registered Nurse (RN) Manager on 03/27/2025 at 3:48 PM, the RN Manager stated the expectation was that food would be served at an acceptable temperature range so residents would enjoy their meals. In an interview with the Administrator on 03/27/2025 at 4:50 PM, she stated she expected residents to eat what they liked, for foods to be palatable, and to receive hot foods hot.

Based on observation, interview, and review of the facility's policy, the facility failed to store food in a safe manner in 3 out of 5 nourishment rooms, on the [NAME], [NAME], and [NAME] Units. Observations on [DATE] and [DATE] of their nourishment rooms revealed unlabeled and undated food and an unclean refrigerator. The findings include: Review of the facility's policy titled, Sanitation Safety, dated ,d+[DATE], revealed food storage areas were to always be clean. Further review revealed stored foods were to be covered, labeled, and dated with the discard date. 1. Observation of the [NAME] Unit Nourishment Room freezer on [DATE] at 5:10 PM revealed one opened container of sherbet that was dated but had no resident identification. In an interview with the Registered Nurse (RN) Manager of the [NAME] Unit on [DATE] at 3:48 PM, she stated she and the volunteer aide checked foods to ensure they were labeled and dated. She stated she expected the nourishment refrigerator to be clean and sanitary, with foods labeled and dated. 2. Observation of the [NAME] Unit Nourishment Room refrigerator on [DATE] at 5:20 PM revealed one popsicle which appeared opened and partially eaten in the top shelf of the freezer door which was not dated or labeled. Additionally, the observation revealed a brown substance under the clear plastic drawers on the bottom shelf of the refrigerator. In an interview with the RN [NAME] Unit Supervisor on [DATE] at 9:03 AM, the Supervisor stated a volunteer aide cleaned the refrigerator, and he assisted as needed. He stated he checked the food items for dates and any outdated food. He stated an unclean refrigerator presented a potential for cross-contamination. 3. Observation of the [NAME] Unit Nourishment Room refrigerator on [DATE] at 8:10 AM revealed a large clear zip lock bag of saltine crackers not dated or labeled. In an interview with the RN Unit Supervisor of the [NAME] Unit on [DATE] at 8:27 AM, she stated the volunteer aide cleaned the refrigerator and completed the temperature logs. She stated she checked that food was dated and not expired, labeled, and the temperature logs to ensure the temperature was in the acceptable range. She stated she expected residents to receive fresh food that was safe to eat. In an interview with the Food Service Operations Manager on [DATE] at 9:08 AM, she stated nursing staff was responsible for the nourishment rooms and refrigerators. She stated it was the volunteer aides' and the managers' responsibility to check the nourishment room refrigerators. In an interview with the Administrator on [DATE] at 4:50 PM, she stated she expected all food to be dated and labeled, and the nourishment rooms to be clean and sanitary.

Based on observation, interview, record review, and facility policy review, the facility failed to protect residents from abuse for 1 of 5 residents investigated for abuse, Resident (R) 134. Review of the facility's investigation revealed the facility determined, on 02/14/2025, R117 entered R134's room and struck him, causing a laceration on R134's forehead that required evaluation at the hospital and closure with steri-strips. The findings include: Review of the facility's policy titled, Resident to Resident Altercations, dated 09/11/2023, revealed facility staff was to monitor residents for aggressive or inappropriate behavior toward other residents. Further review revealed the facility was to identify what might have led to aggressive conduct on the part of one or more residents involved in the altercation. Continued review revealed the facility was to analyze risk factors and care plan appropriate interventions. Review of the facility's investigation, dated 02/14/2025, revealed the facility determined on 02/14/2025, R117 entered R134's room and struck him, causing a laceration on R134's forehead that required evaluation at the hospital and closure with steri-strips. 1. Review of R117 's Admission Record revealed the facility admitted the resident on 04/10/2024 with diagnoses including Alzheimer's disease, dementia with mood disturbance, agitation, and unspecified insomnia. Review of R117's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, indicating severe cognitive impairment. Review of R117's Comprehensive Care Plan [CCP], dated 04/24/2024, revealed the facility identified the resident had an actual behavior problem of wandering into other residents' rooms and lying in their beds. Further review revealed the facility identified R117 was involved in a resident-to-resident altercation on 07/01/2024. Per the CCP, on 02/14/2025, R117 entered another resident's room and hit him several times. Continued review revealed the facility included initial interventions on 04/24/2024 such as provide the resident with meaningful activities, provide a calm atmosphere, anticipate and meet the resident's needs, provide redirection as needed, provide one-on-one if needed, and provide medications as ordered. Additional review of the CCP revealed the facility added the interventions to engage the resident in activities such as watering tomatoes or helping nursing, educating the family on the progressive nature of dementia, and providing a room change as needed on 07/05/2024. Review of R117's Nursing Progress Note, effective date 02/14/2025 at 8:59 PM and written by the Nurse Shift Program Supervisor, stated, Staff was alerted to co-residents' [R134] room after commotion. Resident [R117] was noted to be having an altercation with co-resident [R134]. Resident [R117] immediately removed from co-residents and assessed by nursing staff. Provider notified and order given to send resident out to ER [emergency room ] for evaluation. Family notified and will take Resident [R117] to ER. Resident [R117] remains one-on-one with staff member until family arrives. Observations on 03/24/2025 at 4:50 PM, 03/25/2025 at 9:45 AM, and 03/27/2025 at 2:38 PM revealed R117 wandered throughout the common areas of the [NAME] Unit. Further observations revealed that staff, including the Unit Manager, redirected R117 by providing him with snacks and activities. Per observation, R117 did not attempt to enter any other residents' rooms. Interview with R117 was attempted on 03/24/2025 at 4:34 PM. However, R117 did not respond to the State Survey Agency (SSA) Surveyor's questions. In an interview on 03/25/2025 at 10:07 AM, R117's resident representative stated she believed R117 might have been defending himself, and since no one had seen the altercation begin, it could not be ruled out. She further stated R117's triggers for behaviors included being told what to do instead of being asked. She stated that when she visited, she observed residents who wandered away from the dining room/activity area that were not supervised. 2. Review of R134's Admission Record revealed the facility admitted the resident on 12/05/2024 with diagnoses including Alzheimer's disease, dementia with psychotic disturbance, and violent behavior. Review of R134's annual MDS, with an ARD of 12/11/2024, revealed the facility assessed the resident to have a BIMS score of eight out of 15, indicating moderate cognitive impairment. Review of R134's CCP, dated 12/06/2024, revealed the resident received medication for a diagnosis of psychosis and included interventions of monitoring the resident for behaviors. Review of R134's Nursing Note, effective date 02/14/2025 at 7:20 PM and written by a Licensed Practical Nurse (LPN) stated, This nurse was sitting at desk and heard [sic] rsd [resident, R134] yelling out. [NAME]'s on duty ran to rsd room [R134's room] and explained to this nurse that they found co-rsd [R117] on top of rsd on the ground hitting him. [Sic] Rsd's [Residents] immediately separated and rsd assessed for injury. Bleeding/laceration noted to right eyebrow and bruise noted to left forearm. No other obvious signs of injury noted. Co-rsd assigned to staff member to observe him. Rsd's vitals assessed and WNL [within normal limits], no deficits noted. House charge contacted directly after event who notified physician and family/RP [responsible party]. Observation on 03/25/2025 at 2:01 PM revealed R134 sitting in a recliner in his room on the [NAME] Unit. Further observation revealed no signs of distress. In an interview on 03/25/2025 at 2:03 PM, R134 stated he did not recall a time another resident came into his room. He further stated he did not recall having any verbal disagreements or physical altercations with another resident. Per the interview, R134 stated he felt safe in the facility. In an interview on 03/27/2025 at 3:02 PM, the Nurse Aide State Registered ([NAME]) 14 stated R117 was prone to wandering and was known to wander into other residents' rooms. NASR14 stated staff would redirect a resident who was wandering and would reapproach the resident if they became combative and resisted redirection. Per the interview, NASR14 stated R117 had a history of being combative with staff during care. In further interview, NASR14 stated R117 had not been agitated or resistant to care during the day on 02/14/2025. In continued interview with NASR14, on 03/27/2025 at 3:02 PM, he stated he did not witness R117 enter any other resident's room. However, NASR14 stated, on the evening of 02/14/2025, he had just finished assisting a resident to bed when he heard a commotion and ran toward the noise. NASR14 stated when he arrived at R134's room, he found R117 sitting on top of R134, who was on the floor. In continued interview, NASR14 stated he assisted R117 to his feet and out of the room. Per interview, NASR14 observed a cut on R134's forehead, and R117 had some minor skin tears on his arms. NASR14 stated the facility maintained one-on-one supervision on R117 until the resident's wife came to take him to the hospital. NASR14 stated staff maintained close supervision on R117 when he came back from the hospital, and R117 was more pleasant and easily redirected. In interview on 03/27/2025 at 1:29 PM, NASR11 stated on the evening of 02/14/2025, she was assisting a resident with getting ready for bed when she heard some raised voices in the next room, followed by the sound of something hitting the floor. Per interview, NASR11 ran next door and found R117 on top of R134, who was lying on the ground. She stated NASR14 then entered the room and removed R117, while she assisted R134, got vital signs, and cleaned up R134. In further interview, NASR11 stated R117 liked to wander through the locked unit, and staff would give him activities to redirect him. She stated R117 liked the interactive projector table in the dining room, as well as having a washcloth he could use to dust the counters. Per interview, NASR11 was not aware that R117 had wandered into other residents' rooms and had not seen him in another resident's room prior to 02/14/2025. In an interview on 03/27/2025 at 3:24 PM, NASR12 stated she saw R117 hit R134 while R117 was sitting on top of R134, who was lying on the ground. She stated R117 had not been agitated or given any warning signs that day; however, she knew he was a wanderer. In further interview, NASR12 stated R134 was upset immediately after the altercation and told her that he was shocked someone had hit him in his own room. In an interview on 03/27/2025 at 3:18 PM, Registered Nurse (RN) 1 stated she was working as the house supervisor on 02/14/2025 and responded when staff alerted her to the altercation between R134 and R117. She stated when she arrived at R134's room, staff was assisting R134 off the floor. Per interview, she assessed R134 and notified the physician the resident needed to go to the hospital for evaluation of a laceration to his head, as well as to rule out any internal injuries. In an interview on 03/27/2025 at 10:12 AM, the [NAME] Unit Manager ([NAME]) stated she expected residents on [NAME] to be able to wander freely, even into other residents' rooms. Although, she stated if a particular resident was bothered by that, they could put up Stop signs. She stated the staff took turns as hall monitors to watch for wandering residents. However, she stated there was no hall monitor watching at the time of the altercation. In an interview on 03/27/2025 at 3:47 PM, the Director of Nursing (DON) stated she expected residents on the [NAME] Unit to be allowed to wander freely unless another resident became upset by someone being in their room. She stated if a resident was upset by another resident being in their room, the facility would use Stop signs across the door and redirect the wandering resident away from that room. In a further interview, the DON stated it was very important to supervise wandering residents and prevent altercations. She stated residents with dementia had poor impulse control, which increased the risk for resident-to-resident altercations. Additionally, the DON stated it was important to protect residents from abuse because no one would want to be hit, and no one would want to hear their family member had been hit. In an interview on 03/27/2025 at 4:29 PM, the Administrator stated when residents in the [NAME] Unit wandered into other residents' rooms, it was her expectation to allow residents freedom of movement unless another resident complained. She further stated that most residents would not know if someone walked in their room during the day because most residents stayed engaged in activities in the dining room all day long. The Administrator stated residents being in other residents' room, especially lying in their beds, could cause an issue and raise the risk of a resident-to-resident altercation. The Administrator further stated if a resident complained or if there was a resident-to-resident altercation with a wandering resident, her expectations were for facility staff to supervise the wandering resident and offer them a snack, music, or another favorite activity. The Administrator stated she was notified on the evening of 02/14/2025 of R117 hitting R134 in R134's room. She stated staff did not witness the beginning of the altercation and could not determine exactly what caused it.

Based on observation, interview, record review and review of the facility's Policies, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality while protecting and promoting the rights of the resident for one (1) of thirty-six (36) sampled residents (Resident #43). Observation on 09/05/19 at 3:28 PM, revealed Licensed Practical Nurse (LPN) #9 was standing at Resident #43's bedroom door, on the Washington Unit, calling out, Come on (calling resident by first name), it's time to go check your sugar. Further observation revealed LPN #9 failed to provide for privacy as she performed an accucheck on Resident #43 in front of other residents and staff in the hallway. LPN #9 was then observed to tell the resident aloud, the results of the blood glucose testing while in the hallway, just as multiple residents, staff and volunteers entered and exited the Washington Unit. The findings include: Review of the facility Residents' Rights for Residents in Kentucky Long-Term Care Facilities, Policy, undated, revealed the facility would ensure each resident would be treated with consideration, respect and with full recognition of his/her dignity and individuality, including privacy in treatment and care for his/her personal needs. Further review revealed the facility would ensure Resident Rights were protected and promoted including the residents' right to a dignified existence and self-determination. Review of the facility Insulin Dependent Diabetic Resident Clinical Monitoring Policy, revised 10/2017, revealed licensed nurses would ensure routine and as needed blood glucose monitoring of veterans with insulin dependent diabetes. Further Policy review revealed licensed staff would perform blood glucose monitoring while providing for resident privacy. Review of Resident #43's clinical record revealed the facility admitted the resident on 02/16/94 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 06/24/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #43's (MONTH) 2019 physician's orders [REDACTED]. Please notify provider for any blood sugar less than sixty (60) or greater than four-hundred and one (401) and do recheck and document in follow up section of Medication Administration Record [REDACTED] Further review of physician's orders [REDACTED]. Please notify provider for any blood sugar less than sixty (60) or greater than four-hundred and one (401) and do recheck and document in follow up section of MAR. Review of Resident #43's Comprehensive Care Plan, initiated on 05/09/13, revised on 09/05/19, revealed a focus of [DIAGNOSES REDACTED]. The goal stated the resident would exhibit no complications related to Diabetes through next quarter with target date of 09/20/19. Interventions included administration of ordered Diabetes medication; provide resident/family education regarding medications and importance of compliance; and report signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar) and/or [MEDICAL CONDITION] (high blood sugar) to the provider. Observation on the Washington Unit, on 09/05/19 at 3:28 PM, revealed Licensed Practical Nurse (LPN) #9 was standing at Resident #43's bedroom door, on the Team I hallway, calling out, Come on (calling resident by first name), it's time to go check your sugar. Further observation revealed Resident #43 propelled himself/herself in the wheelchair out of the bedroom, as LPN #9 escorted him/her down Team I hallway to the medication cart. The medication cart was located by the Washington Units nurse's station, at the top of the ramp by the double doors that separated the unit from the Multi-Purpose Room. The double doors to the Multi-Purpose Room were open, allowing flow of traffic through the Washington Unit. Continued observation revealed LPN #9 performed an accucheck for Resident #43 in front of other residents and staff. Additional observation revealed LPN #9 looked at the glucometer (medical device for determining the approximate concentration of glucose in the blood) and told the resident, aloud, the result of the blood glucose testing, just as multiple residents, staff and volunteers entered and exited the Washington Unit by way of the ramp. Interview with LPN #9, on 09/05/19 at 3:35 PM, revealed blood sugar testing was not an invasive procedure and it was fine to do it wherever the resident may be located at the time. Further interview revealed she had been employed with the facility for eight (8) months and had never received any educational material, training or orientation related to Residents' Rights, or Privacy/Dignity/Confidentiality. Additional interview revealed she had received no guidance or directive in relation to when/where staff were permitted or forbidden to perform accuchecks. LPN #9 stated it was her belief that as long as the resident was agreeable to do it, it was permissible to do. Continued interview with LPN #9, revealed, When residents live in a nursing home together, there's no way to control what one resident does or does not know about another resident. Everyone knows everything about everyone. LPN #9 stated she did not know the reason she requested Resident #43 to come out of his/her room for blood glucose monitoring. Per interview, she just had a habit of bringing the residents to the medication cart for accuchecks and to administer residents' medications. Interview with Resident #43, on 09/05/19 at 3:45 PM, revealed he/she preferred to have blood sugar testing performed in his/her room or in another private area. Further interview revealed the nurses usually tested his/her blood sugar in his/her room, but LPN #9 always checked his/her blood sugar at the medication cart, in the corridor/hallway. Continued interview revealed he/she did not appreciate other residents, volunteers, and staff who were not providing care for him/her, knowing his/her diagnoses. Resident #43 stated he/she did come out to the medication cart for blood sugar testing when LPN #9 requested him/her to do so. Interview with the Washington Unit Manager (UM), on 09/05/19 at 3:55 PM, revealed LPN #9 had been employed with the facility through agency for the last eight (8) or nine (9) months. Further interview revealed the behavior displayed by LPN #9 did not represent the beliefs and values of the facility staff, nor did it honor the resident's right to privacy, confidentiality, or dignity. Continued interview revealed LPN #9 had received educational material, training, and completed competency testing on the facility's policies including, Insulin Dependent Diabetic Clinical Monitoring as well as Resident Rights. Additional interview with the UM, revealed LPN #9 should have taken the medication cart with glucose monitoring supplies to the hallway by the door of Resident #43's room, and performed the accucheck in the resident's room. Per interview, LPN #9 should not have requested the resident to leave his/her room for the accucheck or talked about the resident's blood sugar in hearing distance of others, as this violated the resident's right to privacy and confidentiality. The UM stated it was her expectation for all procedures, whether invasive or non-invasive, to be performed in the resident's room or another private location. Per interview, other residents, staff who was not caring for the resident, visitors, volunteers, and others should not have access or knowledge of the resident's condition, diagnosis, medication or treatment. Interview on 09/06/19 at 02:04 PM, with the Staff Development Coordinator (SDC), revealed staff was trained to honor and maintain the resident's right to privacy, confidentiality and dignity by performing all procedures, whether invasive or noninvasive, (i.e. administering medications, performing dressing changes, checking blood sugar) in the resident's room or in another discreet location. Further interview revealed the SDC provided all newly hired staff (agency and facility) copies of the Residents' Rights booklet, which contained the facility's Residents Rights Policy during the first day of orientation. The SDC stated she specifically and extensively reviewed and tested staff's knowledge of residents' privacy, confidentiality and dignity and submitted documented evidence of competencies completed by LPN #9 for review. Continued interview with the SDC, revealed she often reminded staff during facility rounds to pull privacy curtains, shut resident doors and window blinds when providing direct care, to knock on resident doors to announce presence before entering as well as not to discuss or perform resident care in hallways. The SDC stated it was her expectation for all staff to honor and respect the resident's right to privacy, confidentiality and dignity by adhering to the facility's policies and procedures while providing care to the residents. Interview with the Director of Nursing (DON), on 09/06/19 at 2:36 PM, revealed it was her expectation for staff to perform all procedures, non-invasive or invasive, (i.e. checking blood sugar, administering medications/insulins, performing treatments) in the resident's room or another private area. Further interview revealed she expected staff to meet the resident's care needs while ensuring the resident's privacy, confidentiality and dignity was preserved and maintained. Continued interview revealed LPN #9 should have performed Resident #43's accucheck in his/her room or in another discreet location, and not in the corridor/hallway, as this was a violation of the resident's privacy and confidentiality. Additionally, the DON stated she expected staff to ensure resident's rights were honored at all times and not to discuss their blood sugar results in front of others. Interview on 09/06/19 at 2:59 PM with the Administrator, revealed it was his expectation staff provide care for residents while fostering independence, and preserving dignity at all times. Further interview revealed the residents at his facility were special human beings, as they were the nation's heroes/veterans and Staff was expected to treat them that way. Continued interview revealed the Administrator expected staff to follow facility Policies at all times.

Based on interview, record review and review of the facility's Policy, it was determined, the facility failed to ensure residents were free from abuse for four (4) of six (6) sampled residents (Resident #1, Resident #2, Resident #3 and Resident #4). 1) On 06/15/19, Resident #1 and Resident #2 had a verbal altercation that escalated into a physical altercation resulting in a bruised area to the left arm of Resident #2. 2) On 07/01/19, Resident #3 and Resident #4 had a verbal altercation that escalated into a physical altercation resulting in a small skin tear to the right elbow of Resident #4. The findings include: Review of the facility's Policy, titled Abuse Policy and Procedures-Abuse Prevention, revised 02/17/19, revealed it was the goal of the facility to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. Further review of the policy revealed the facility's abuse prevention program included, but was not limited to, seven key (7) components: screening, training, prevention, identification, investigation, protection, reporting/response. Continued policy review revealed the Prevention and Identification components of the abuse prevention plan, which, revealed there would be an assessment, care planning, and monitoring of residents with needs and behaviors that could lead to conflict or neglect. Examples of this would include the following: residents with a history of aggressive behaviors, residents with behaviors such as entering other resident's rooms, residents with self-injurious behaviors, residents with communication disorders, those requiring heavy nursing care, and/or those residents who are totally dependent on staff for daily care needs. 1) Review of the Facility's Self-Reported Incident Form and attached Investigation, dated 06/15/19, completed by Social Services Director (SSD), revealed on 06/15/19 at approximately 10:30 AM, Resident #1 entered the Eisenhower Unit sitting area, shouting out, You're all here to die, I hope you know that, startling Resident #2 as he/she was sitting in the recliner, in the area with eyes closed. Further review revealed Resident #2 awakened and stood up, pointed his/her finger at Resident #1 and told the resident to go away. Resident #1 picked the walker up over his/her head and shook it at Resident #2. Continued review of the Investigation, revealed Resident #2 attempted to take the walker away from Resident #1 as he/she began swinging the walker and Resident #2 was struck on the left forearm. Additional review revealed Licensed Practical Nurse (LPN) #2 separated the residents and called out for assistance from co-staff to remove the walker. LPN #2 performed skin assessments on both residents and noted a four (4) inch purple discoloration to Resident #2's left lower arm. Further review of the report, revealed the Medical Provider (MP) gave new orders for Resident #1 to receive [MEDICATION NAME] fifty (50) milligrams (mg) ( antipsychotic medication) one (1) time dose now for agitation/anxiety. Both Resident #1 and Resident #2 were placed on every fifteen (15) minute checks. Continued review revealed Registered Nurse (RN) #1 notified the on-call nurse manager, Director of Nursing (DON) and the Administrator of the altercation on 06/15/19 at 11:00 AM. Review of Resident #1's clinical record revealed the facility admitted the resident on 06/19/18 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/29/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) which indicated moderate cognitive impairment. The facility further assessed the resident as having verbal behavioral symptoms directed towards others such as yelling, cursing, and threatening staff and co-residents and other behavioral symptoms not directed at others, such as pacing, wandering and other physical symptoms for one (1) to three (3) days over the assessment period. Continued MDS review revealed the facility assessed the resident as requiring physical assistance of one (1) with transfers, ambulating in room and ambulating in corridor. Review of Resident #1's Comprehensive Care Plan, initiated 12/07/18, revealed a focus for the need to observe the resident's mood and behavior due to the potential for altered mood and behavior patterns including: resistive to care, verbal and physical aggression, agitation, and cursing at staff, related to impaired cognition due to the [DIAGNOSES REDACTED]. The goal stated Resident #1 would not cause harm to self or others through the next review date of 07/28/19. The interventions included: administration of medications as ordered by medical provider, observation of mood and behavior, report symptoms of depression to medical provider, social services and/or nursing, when physically aggressive and/or yelling/cursing at others-ask resident to come with staff to a quiet place to talk about what is wrong, allowing resident to vent frustrations and problem-solve, permissible to tell resident physical aggression and yelling is inappropriate, and intervene as needed to protect the safety and rights of others. Review of Resident #1's Nursing Progress Note, dated 06/15/19 at 12:44 PM, completed by RN #1, revealed Resident #2 was in the television area, seated in a recliner near nurse's station, with eyes closed. Resident #1 entered the television area, yelling, You're all here to die. I hope you know that. Further review of the progress note, revealed, Resident #2 stood up from the recliner, pointed at Resident #1, and told the resident to go away. Resident #1 raised his/her walker up over his/her head and began shaking it. Resident #2 attempted to take the walker away from Resident #1 but he/she began swinging it and struck Resident #2 on the arm. Continued review of the progress note, revealed, LPN #2 intervened and separated the residents, calling out for assistance from co-staff. Additional review of the progress note revealed LPN #2 performed a skin assessment on Resident #1 with no documented evidence of injury or complaints. Further review of the progress note revealed LPN #2 contacted Resident #1's medical provider and received a new one (1) time order to administer [MEDICATION NAME] fifty (50) milligrams (mg) by mouth for anxiety and agitation and [MEDICATION NAME] fifty (50) mg one (1) tablet by mouth every eight (8) hours as needed for anxiety/agitation for fourteen (14) days. Resident #1 was placed on every fifteen (15) minute checks. Observation of Resident #1, on 07/09/19 at 10:45 AM, revealed the resident was briskly ambulating about unit hallways and television area, stopping to speak with co-residents or staff members. Further observations revealed Resident #1 smiling with the occasional chuckle while engaged in conversation or briefly chatting. Interview with Resident #1, on 07/09/19 at 10:45 AM, revealed he/she could not recall an incident related to Resident #2 and could not imagine he/she would do such a thing to a friend. Per interview, Resident #1 was having difficulty with remembering things but could surely remember hitting someone with my walker. Further interview with Resident #1 revealed he/she was concerned that no one had seen Resident #2 on the unit recently. Review of Resident #2's clinical record revealed the facility admitted the resident on 07/11/18 with [DIAGNOSES REDACTED]. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 06/12/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment. The facility further assessed Resident #2 to have physical behavioral symptoms directed at others, such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually; verbal behavioral symptoms directed towards others, such as threatening, screaming and cursing; and other behavioral symptoms not directed at others, such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing of food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds, which occurred one (1) to three (3) days during the assessment period. The facility assessed Resident #2's behavioral symptoms of rejecting care to have occurred one (1) to three (3) days during the same assessment period with wandering behavior worsening from prior MDS Quarterly assessment, dated 03/29/19. Further review of the MDS, revealed the facility assessed the presence of Resident #2's behavioral symptoms placed the resident and others at significant risk for physical illness or injury. The facility further assessed the presence of resident's behavioral symptoms to significantly interfere with the resident's care, participation in activities and social interactions and disrupt other resident's care and living environment. Additionally, the facility assessed Resident #2 to require physical assistance of one (1) with transfers, walking in corridor and for locomotion on and off the unit. Review of Resident #2's Comprehensive Care Plan, initiated on 06/12/19, and revised on 06/26/19, revealed a focus for potential to demonstrate physical and/or verbal behaviors such as resisting direct care by raising fist, cursing and/or threatening staff and/or peers and defecating/urinating in inappropriate places due to [DIAGNOSES REDACTED]. The goal stated the resident would not harm self or others through the next review date of 09/12/19. The interventions included the following: analyzing key times, places, circumstances, triggers and what de-escalates behavior and document, assessment and anticipation of resident needs such as food, thirst, toileting needs, comfort level (positioning, pain), communicate to provide physical and verbal cues to alleviate resident's anxiety, give positive feedback, assist with verbalization of source of agitation, assist with setting goals for more pleasant behaviors, encourage resident to seek out staff when agitated, documenting any observed behavior and any attempted interventions in clinical record, give resident as many choices as is possible related to care and activities, modification of resident's environment such as adjusting room temperature to comfortable level, reduction of noise, dimming lights, placing familiar objects in room, keeping door closed, monitoring/documenting and reporting of dangerous behavior to medical provider and psychiatric/mental health consults as indicated. Review of Resident #2's Nursing Progress Note, dated 06/15/19 at 12:18 PM, completed by RN #1, revealed the resident was sitting in the television area, in a recliner, with his/her eyes closed, resting. Further review of the progress note revealed Resident #1 entered the television area, loudly yelling, You're all here to die. I hope you know that. Resident #2 stood up from the recliner, pointed at Resident #1 and told the resident to go away. Continued progress note review revealed Resident #1 picked up his/her own walker, raised it above his/her head and began shaking it at Resident #2. As Resident #2 attempted to remove the walker from the resident, Resident #1 began swinging the walker, striking Resident #2. LPN #2 intervened, separated the residents and called out for assistance from co-staff. Additional review of resident's progress note revealed LPN #2 assessed Resident #2 to have an approximate four (4) inch purple discoloration to left lower arm with no reported complaints of pain or discomfort at the time of assessment. Resident #2 was also placed on every fifteen (15) minute checks with skin assessment completed by LPN #2. The State Agency Representative attempted a Phone Interview with LPN #2, nurse assigned to provide care for Resident #1 and Resident #2, on 06/15/19, on 07/09/19 at 10:20 AM, on 07/09/19 at 3:26 PM and again on 07/10/19 at 8:49 AM and 12:55 PM. However, LPN #2 did not answer the representative's call and no voicemail was available to leave a message. The State Agency Representative attempted a Phone Interview with RN #1, on 07/09/19 at 10:22 AM, on 07/09/19 at 10:23 AM, again on 07/09/19 at 11:00 AM and on 07/10/19 at 12:50 PM. The State Agency Representative received a rapid busy signal with each call placed to RN #1 and no secondary contact number was available. Interview with Nursing Assistant State Registered (NASR) #2, on 07/10/19 at 10:32 AM, revealed she was assigned to duty on Eisenhower Unit, location of incident and where Resident #1 and Resident #2 resided, as per usual routine, on 06/15/19. Further interview revealed NASR #2 was in the dining room, preparing residents for lunch service, when she overheard what she believed to be male voices cursing and screaming from towards the nurse's station. NASR #2 reported she was unable to leave residents in dining area unsupervised, so she stayed in dining room and awaited instruction from LPN #2. Continued interview revealed LPN #2 did not request her assistance at that time. NASR #2 reported she later learned of the altercation between Resident #1 and Resident #2 from LPN #2 after serving resident's lunch when she was instructed Resident #1 and Resident #2 were being placed on every fifteen (15) minute checks. Additional interview with NASR #2 revealed both Resident #1 and Resident #2 were known to have behavioral problems prior to the altercation on 06/15/19 and had interventions in place. NASR #2 advised she was unsure if any interventions were implemented prior to incident, but felt interventions should have been implemented prior to Resident #2 sustaining an injury. Further, NASR #2 revealed staff have access to all resident's Care Plans in a condensed version that can be carried in the pocket of the staff uniforms. Interview with NASR #3, on 07/10/19 at 2:35 PM, revealed he was assigned to Eisenhower Unit, location of incident and where Resident #1 and Resident #2 resided, as per usual routine, on 06/15/19. NASR #3 added he and NASR #2 were assigned to provide care to Resident #1 and Resident #2 on 06/15/19. NASR #3 reported he was in the dining room assisting and preparing residents for lunch prior to the incident occurring between Resident #1 and Resident #2. Further interview with NASR #3, revealed he was assisting another resident when he heard LPN #2 yelling loudly from the nursing station. NASR #3 reported he quickly ran from the dining room to investigate and assist the nurse. Continued interview revealed, upon arrival to the sitting area, near the nurse's station, NASR #3 observed Resident #1 holding a walker up over his/her head, shouting and cursing at Resident #2 while LPN #2 stood between the two (2) residents. LPN #2 requested NASR #3 assist to separate the residents and escort Resident #1 to the dining room as she assisted Resident #2 to his/her room. NASR #3 reported he assisted Resident #1, with some difficulty redirecting, to the dining area and was able to convince the resident that it may be best to leave the walker in his/her room for rest of the day. Further interview revealed Resident #1 continued to shout, curse and threaten to get a gun and shoot Resident #2 throughout the dining room area. NASR #3 reported Resident #1 and Resident #2 were placed on fifteen (15) minute checks for several days following the altercation but was unsure if LPN #2 had implemented any additional interventions for either resident as per their Care Plan, prior to the incident occurring. NASR #3 advised although Resident #1 and Resident #2 had verbal and physical behaviors, he had not observed any verbal/physical aggression from either resident that he recalls that day, prior to the altercation. NASR #3 reported he is aware of his resident care needs by obtaining report from the nurses and by referring to the resident's Care Plan. NASR #3 stated he carried a small pocket-version of each of his assigned resident's Care Plans with him at all times to refer to as resident needs are ever changing. Additional interview revealed it was important for staff to be proactive and protect residents from abuse. NASR #3 reported staff should have implemented interventions, as per each resident's Care Plan, to protect these two (2) residents from abuse, prior to Resident #2 sustaining an injury. NASR #3 added he was usually able to redirect Resident #1 by distracting the resident's attention away from the source of agitation or could have resident sit down and talk quietly with him about fishing or other outdoor hobbies. However, NASR #3 reported Resident #1's behavior, in his opinion, was progressively worsening with increased agitation, yelling, and cursing at co-residents/staff and being resistive with care. NASR #3 reported observations of Resident #2 with worsening agitation and violent behavior recently as well, adding, Resident #2 recently slapped a nurse and pulled the trim off from the nurse's station while upset for no known cause. Interview with Social Services Director (SSD), on 07/10/19 at 12:00 PM, revealed she was responsible for ensuring the facility's resident investigations were completed in a timely and thorough manner. Further interview, revealed the SSD facilitated interdisciplinary team meetings (IDT) to develop plans for addressing resident concerns and communicating those plans to other entities. SSD reported she was responsible for ensuring staff completed resident assessments, resident and staff interviews, made medical provider, family/power of attorney notifications and summarized reportable incidents, the facility's investigative findings and the conclusion of those investigations. Continued interview with SSD revealed, on 06/19/19, she and the IDT team met to discuss the 06/15/19 incident between Resident #1 and Resident #2 and determined a therapeutic calendar for the Eisenhower Unit/Neighborhood would be reviewed and modified for both the types of therapeutic activities and appropriate timing of such activities. The SSD reported the physical environment of the seating area close to the nurse's station was modified to create a more conversational style seating and to decrease congestion in the area. Continued interview revealed staff continue to redirect and offer distractions to residents, such as going outside when weather permits, redirection to another location if agitated, and allowing opportunities to vent frustrations. SSD reported Resident #1's long-term plan was to remain at the facility on a secured unit without a walker. SSD advised Resident #1 was re-evaluated by the Physical Therapy Department following the incident and was advised he/she could safely ambulate independently without the use of a walker. Resident #1's son removed the walker from the facility. SSD reported Resident #1's Comprehensive Care Plan was revised on 06/19/19 to include the altercation with Resident #2. Goal stated resident would not harm himself or others through next review date of 07/28/19. SSD reported several revised Care Plan Interventions for Resident #1, including: Analyzation of key times, places, circumstances, and triggers that escalate behaviors and document, observation and documentation of behavior and any attempted interventions in resident's clinical record, monitor/document and report danger to self or others to Medical Provider, Psychiatric/Mental Health consults as indicated, intervene before resident agitation escalates, guide resident away from source of distress, engage calmly in conversation-if response is aggressive and staff were to walk away calmly and approach at later time. Additionally, SSD reported Resident #2, had shown increased agitation, physical aggression and becoming more resistive to care recently. Continued interview revealed, Resident #2 was re-evaluated by the Medical Provider, on 06/17/19, with new orders for a urinalysis, to hold [MEDICATION NAME] medication for next three (3) days, and to continue administration of [MEDICATION NAME] (Antipsychotic). [MEDICATION NAME] was to be administered as one (1) ten (10) mg tablet by mouth twice daily for [MEDICAL CONDITION] and [MEDICATION NAME] one (1) five (5) mg tablet by mouth every twelve (12) hours as needed for psychotic aggression/[MEDICAL CONDITION]. Per interview, the Medical Provider re-evaluated Resident #2 again on 06/20/19 for on-going behaviors and delusions, then transferred to the hospital for psychological evaluation. Resident #2 remains hospitalized at this time. Additional interview with SSD revealed all residents had the right to be free from abuse. Interview with Director of Nursing (DON), on 07/10/19 at 3:20 PM, revealed, she was made aware of altercation between Resident #1 and Resident #2 by nurse supervisor/house charge nurse, RN #1 on duty the day of the altercation. Per interview she was notified by RN #1 of the altercation between Resident #1 and Resident #2 on 06/15/19; however, was unable to give a specific time she was notified. The DON advised, RN #1 reported the LPN #2 had advised her Resident #1 had come up through the television area, yelling, You're all here to die. I hope you know that. Resident #2, who had been resting with eyes closed, in the television area, woke up angry. Continued interview with the DON, revealed RN #1 reported to her, LPN #2 advised Resident #2 had stood up out of the chair and told Resident #1 to go away. Resident #1 raised the walker above his/her head, shaking it at Resident #2. As Resident #2 attempted to take the walker from Resident #1, Resident #1 began swinging the walker, striking Resident #2 on the arm. Additional interview with DON revealed LPN #2 reported she immediately intervened to separate the residents and called out for co-staff to assist. The DON stated RN #1 advised her that LPN #2 reported, NASR #3 responded and assisted Resident #1 to dining room area as LPN #2 assisted Resident #2 to his/her room to perform a skin assessment. Continued DON interview, revealed, LPN #2 noted and RN #1 verified an approximate four (4) inch purple discoloration to Resident #2's left lower forearm. Further interview with the DON revealed RN #1 and LPN #2 placed both residents on every fifteen (15) minute checks and notified both resident's power of attorneys and the Licensed Nursing Home Administrator (LNHA). The DON advised all residents have the right to be free from abuse. 2) Review of the Facility's Self-Reported Incident Form and attached investigation, dated 07/05/19, completed by the DON, revealed on 07/01/19, at approximately 4:25 PM, an unwitnessed incident occurred in the Roosevelt/ Lincoln Dining Room between Resident #3 and Resident #4. Further review of the investigation, revealed Resident #3 reported he/she struck Resident #4 after observing the resident spitting on the dining room floor and fussing to the resident failing to stop spitting after being asked to do so several times. Continued review revealed Resident #3 approached Resident #4, who advised Resident #3 to come over there. Resident #4 swung to strike Resident #3 but failed to make contact. Resident #3 struck back in retaliation, striking Resident #4, causing the resident to fall to the floor. Further review of the investigation revealed Resident #4 was unable to recall where he/she was struck, advising simply, I fell . Per the investigation report, the residents were immediately separated and assessed. Resident #4 complained of lower back and shoulder pain and was noted to have a small skin tear to the right elbow. The Medical Provider was on site and assessed Resident #4 with orders to send him/her to the hospital for further evaluation. Resident #4's skin tear was cleansed and a Band-aid applied prior to transport. Continued review revealed Resident #4 returned to facility, on 07/01/19 at approximately 8:05 PM, with a normal neurological assessment noted upon return. Resident #3 and Resident #4 were placed on fifteen (15) minute checks. Additional review revealed the IDT team met to discuss non-pharmacological interventions for the residents. Resident #4 was provided a cup with a cup holder for his/her walker for spitting and staff would encourage the resident to spit into cup instead of on the floor. The Medical Provider re-evaluated Resident #4's medications with no changes made. Resident #3 and Resident #4 were offered a change of seating in the dining room but both declined the offer. Resident #3 was reminded to notify staff, who would clean up the dining room area if needed. Resident Care Plans were revised to include altercation and reflect new interventions. Per review of the investigation, there have been no additional conflicts between Resident #3 and Resident #4, nor has there been any negative outcomes. Review of Resident #3's clinical record revealed the facility admitted the resident on 07/25/18 with [DIAGNOSES REDACTED]. Review of Resident #3's Annual Minimum Data Set (MDS) Assessment, dated 07/01/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS, revealed the facility assessed the resident to demonstrate physical behavioral symptoms directed towards others one (1) to three (3) days over the assessment period and verbal behavioral symptoms directed towards others occurred one (1) to three (3) days over the assessment period. Continued MDS review revealed the facility further assess Resident #3's overall presence of behavioral symptoms to significantly interfere with the resident's care and place the resident at significant risk for illness or injury. Additionally, the facility assessed Resident #3's behavioral symptoms to place others at significant risk for physical injury, intrude on others privacy and/or activity and disrupt the care and living environment of others. Further facility assessment revealed Resident #3 rejected care necessary to achieve goals for health and well-being one (1) to three (3) days over the assessment period, indicating Resident #3's behavior had worsened from prior MDS assessment on 04/08/19. Review of Resident #3's Comprehensive Care Plan, initiated 10/23/18, revealed a focus for potential to demonstrate verbal and physical behaviors towards others such as cursing and threatening to hit them related to the [DIAGNOSES REDACTED]. Additional resident behaviors included the following: making sexual inappropriate comments or attempts to touch others, making racial slurs, urinating in his/her trash can when urinals have been provided, intentionally smearing feces on own body, defecating on floor, locking shared bathroom door as to not allow others to use, and placing lit cigarettes into pouch on walker. The goal stated the resident would not harm self or others through the review date of 09/23/19. The interventions included analyzation of key times, places, circumstances, triggers escalating behaviors and document, assessing and anticipating resident's needs such as hunger, thirst, toileting needs, comfort level, body positioning. Additional interventions included the following: providing physical and verbal cues to alleviate anxiety, giving resident positive feedback, assisting with verbalization of source of agitation, assistance with goal setting for more pleasant behavior, encouraging resident to seek out staff member when agitated and providing resident with as many choices as possible regarding care and activities. Review of Resident #3's Nursing Progress Note, dated 07/01/19 at 4:25 PM, completed by the DON, revealed the resident reported he/she became upset when Resident #4 spit on the floor in the dining room. Further review of the Progress Note revealed Resident #3 reported to the DON, Resident #4 attempted to strike him/her but was unsuccessful. Resident #3 reported he/she then struck Resident #4, knocking co-resident to the floor. Continued review of the Progress Note revealed this was an unwitnessed incident. Additional review of the Nursing Progress Note revealed staff in the dining room immediately separated residents. Further review revealed SSD interviewed Resident #3 and Resident #4 regarding the altercation. Skin assessments were performed on the residents with messages left for the POA to return the call. The Medical Provider and Administrator were notified of incident. Resident #3 and Resident #4 were placed on fifteen (15) minute checks. Review of Resident #4's clinical record revealed the facility admitted the resident on 04/04/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Annual MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of six (6) out of fifteen (15), which indicated severe cognitive impairment. The facility further assessed the resident as having no physical or verbal behavioral symptoms directed towards others during the assessment period. Further MDS review revealed the facility assessed Resident #4 as having other behavioral symptoms not directed towards others described as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or other disruptive sounds, occurring one (1) to three (3) days during the assessment period. Continued MDS review revealed the facility assessed the resident as requiring supervision with set up assistance only for transfers, dressing and toilet use. Additional review revealed the facility assessed the resident as independent with bed mobility, walking in room and corridor, and with locomotion on/off unit. Resident #4 required only set up assistance with eating. Review of Resident #4's Comprehensive Care Plan, initiated on 04/13/17, revised on 07/03/19 following altercation with Resident #3, revealed a focus for behavior problem with potential to cause harm related to [DIAGNOSES REDACTED]. prep line in the Dining Room, attempted to wander into peers rooms, laying in floor intentionally, have tendency to spit on floor when eating which is disturbing to other residents. The goal stated the resident would not cause harm to self or others through the review date of 08/05/19. There were several interventions which included: remaining non-judgmental when confronting negative behavior, encouraging family to remain active/supportive of resident, establishing consistent staff approaches to deal with behavior, provide one on one supervision and give clear explanation of all car

Based on observation, interview and review of the facility policy, it was determined the facility failed to store and distribute food in a safe manner. Observations on [DATE] of the Lincoln and Washington Unit resident nourishment refrigerators, revealed staff did not rotate food products according to date, did not discard outdated food products and resident food items were not identification or dated. The findings include: Review of Facility policy titled, Foods Brought by Family/Visitors, dated ,[DATE], revealed food items in the pantry refrigerator, must be covered, labeled with resident name, and a discard date. Continued review revealed food would be discarded within seven (7) days of preparation or opening. Further review revealed foods would be discarded by the date on the package if that date were sooner than the seven (7) days the food is received. Review of Facility policy titled, Food Storage, dated ,[DATE], revealed Refrigerated ready-to-eat and potentially hazardous foods must be marked to indicate the date by which the food must be consumed or discarded. Further review revealed opened food items should be dated seven (7) calendar days after the original package is opened. Further review of the policy revealed food items with a specific expiration date unopened or opened are discarded by the original package expiration date. Observation of the Lincoln unit nourishment refrigerator, on [DATE] at 12:21 PM, revealed a clear container of Thickened Liquid Water, two (2) cottage cheese containers not identified with a resident name or date that contained green beans and greens. Continued observations of the nourishment refrigerator revealed a large plate of food in a plastic grocery bag dated [DATE] with no resident name. Further observation revealed a large grocery bag of grapes with no resident label. Observations of the Washington unit nourishment refrigerator, on [DATE] at 12:39 PM, revealed eight (8) expired milk cartons dated [DATE] and seven expired milk cartons dated [DATE]. Continue observation of the nourishment refrigerator revealed one (1) resident sandwich not dated. Interview with Nurse Aide #1, on [DATE] at 10:35 AM, revealed she places the order and stocks the refrigerators on the Lincoln unit. Continued interview revealed she is responsible to rotate and checks dates. Further interview revealed she was in the process of cleaning out the refrigerator and had to stop to go to an appointment with a resident. Interview with Registered Nurse/Lincoln Unit Nurse Manager #3, on [DATE] at 10:40 AM, revealed it was the responsibility of the aides to maintain the nourishment refrigerator. Continued interview revealed food items should be labeled with Resident's name, date and time received. Further interview revealed all food items brought in by the family and stocked food items should be dated. Interview with Aide #2, on [DATE] at 1:00 PM, revealed she is responsible for ordering resident nourishments each Thursday on the Washington unit. She further revealed she is responsible to rotate food stock and throw out outdated food items. Interview with Aide #3, on [DATE] at 1:05 PM, revealed she was responsible for ordering food items on Monday for the Washington Unit. Continued interview revealed food items were not rotated and the outdated food items were not removed from the refrigerator. She further revealed she did not know about the cottage cheese containers; however, the containers needed to be discarded. Interview with Registered Nurse/Washington Nurse Manager #4, on [DATE] at 1:15 PM, revealed Aide #3 takes the lead on stocking the refrigerator. Continued interview revealed food was stocked daily, rotated and discarded timely within the week. Interview with Director of Nursing, on [DATE] at 12:52 PM, revealed it was her expectation for anything stored in the kitchenette to be labeled and dated per the facility's policy with the resident's name and date. Further interview revealed food items should be discarded per the facility's policy. Interview with the Administrator, on [DATE] at 12:45 PM, revealed it was his expectation for staff to follow the facility's policy related to the storage of food items.

Based on interview, record review and review of the facility policy, it was determined the facility failed to notify the Medical Provider when there was a potential need to alter a medical treatment for one (1) of thirty-one (31) sampled residents (Resident #114). The facility failed to notify the physician on 11/16/18 and 11/18/18 when Resident #114's blood glucose levels were above four hundred (400). The findings Review of the facility policy titled, Insulin Dependent Diabetic Resident Clinical Monitoring, dated 10/20/17, revealed licensed nurses would ensure routine and as needed (PRN) blood glucose monitoring of resident with insulin dependent diabetes. Continued review revealed licensed nurses would observe the resident for signs or symptoms of [MEDICAL CONDITION] (high blood glucose levels) and if symptoms were present, would inform the Medical Provider as well as document the following in Point Click Care: (1) the assessment; (2) the interventions; and (3) the evaluation of effectiveness. Further review revealed If the reading of a finger stick blood glucose was 401 or greater, staff would inform the Medical Provider via the secure communication in Point Click Care (PCC). Review of Resident #114's medical record revealed the facility admitted Resident #114 on 10/30/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum data Set (MDS) Assessment, dated 11/05/18, revealed the facility assessed Resident #114 as having a Brief Interview for Mental Status (BIMS) score of twelve (12 ) out of fifteen (15), indicating the resident was moderately cognitively impaired. Review of a Physician's order, dated 10/30/18, revealed a verbal order was given for Accu Checks (blood glucose monitoring) to be performed two (2) times each day for health maintenance related to Type Two (2) Diabetes Mellitus without complication. Review of Resident #114's Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. Further review revealed on 11/18/18, the resident's blood glucose level was four hundred and ten (410) at 7:00 AM, HI at 11:30 AM and four hundred thirty-five (435) at 5:00 PM; however, there was no documented evidence the physician was notified of the elevated levels. Review of the Nursing Notes, dated 11/16/18, revealed no documented evidence the secure communication system in Point Click Care was activated per the facility's policy. There was no documented evidence the physician was notified of the elevated blood glucose levels. Review of the Point Click Care progress notes, dated 11/16/18 and 11/18/18, revealed the box to inform the Medical Provider via the secure communication in Point Click Care, was not checked for the Medical Provider to be notified of the elevated blood glucose levels. There was no documented evidence the physician was notified of the elevated blood glucose readings, per the facility's policy. Review of the Nursing Note, dated 11/18/18 at 12:44 PM, and signed by Licensed Practical Nurse (LPN) #1, revealed Resident #114's blood glucose was checked two (2) times and read out to be HI each time. Per the note, the resident had no signs or symptoms of [MEDICAL CONDITION], insulin was given and the resident was encourage to drink water and eat a low sugar diet. There was no documented evidence the secure communication system in Point Click Care was activated to notify the physician of the elevated blood glucose readings, per the facility's policy. Interview with Resident #114, on 12/04/18 at 10:15 AM, revealed he/she only received insulin once each daily, and no extra insulin was given. Continued interview revealed he/she expressed concern with knowing his/her blood sugar levels were too high, and he/she feels high in the clouds when his/her blood sugar is elevated. Further interview revealed he/she would like to know how to control the high blood sugars levels other than with diet. Interview with Licensed Practical Nurse (LPN) #1, on 12/05/18 at 1:45 PM, revealed Resident #114's blood glucose levels do run high and the process was to flag the information in Point Click Care (PCC) for the Medical Provider to review the blood sugar levels. Further interview revealed the Medical Doctor (MD) should be notified when a resident was symptomatic and the blood sugars were high; however, he was not aware of what the facility's policy was. Additional interview revealed he did not know why the high blood glucose levels on 11/16/18 and 11/18/18 were not flagged for the MD to review. Per interview, the MD should be made aware of the high levels so changes in medications could be made. Interview with LPN #2, on 12/05/18 at 1:55 PM, revealed Resident #114 was a new admission and his/her blood glucose levels have been running high. Per interview, notification of the high levels was sent to the MD by checking the box in PCC and staff should call the MD when the resident was symptomatic and blood sugars are running high. Interview with(NAME)Unit Manager, on 12/05/18 at 2:15 PM, revealed the nurse checks the box in PCC to notify MD of the high blood glucose levels. Per interview, it was her expectation that the box be check to notify the MD of the high levels to initiate medication changes as needed, per the facility policy. Interview with the Advance Practice Registered Nurse (APRN), on 12/06/18 at 10:45 AM, revealed she runs a twenty-four (24) hour daily report from the information entered into the PCC. Per interview, this report notifies her to review the elevated glucose levels, when the notification box is checked. Per interview, if staff do not mark the box for the MD to review, it will not be on the report and she would not be notified to evaluate the elevated level and titrate or change the medications as the resident needed. Continued interview revealed it was her expectation that staff would call her for blood glucose levels above four hundred (400) to ensure the resident's needs were met. Interview with Director of Nursing (DON), on 12/06/18 at 10:56 AM, revealed the facility policy states for blood glucose levels greater than four hundred (400), with symptoms, that staff should call the Medical Provider to report the findings. Continued interview revealed for asymptomatic residents with a high glucose level, staff should enter the information into PCC and check the box, which notifies the Medical Provider of the high level via the secure communication in PCC. Per interview, it was her expectation for staff to follow the facility's policy and mark the box in PCC to indicate the high glucose level so the physician would be alerted to the abnormal value to allow for any medication changes to be made in a timely manner. Interview with Administrator, on 12/06/18 at 10:45 AM, revealed it was his expectation was for staff to follow the facility's policy and to report high blood glucose levels to the Medical Provider so they could address the abnormal values for the health and well-being of the residents.

Based on observation, record review, and interview it was determined the facility failed to develop and implement a comprehensive person-centered care plan for two (2) of thirty-one (31) sampled residents (Resident #35 and Resident #114). Resident #35 exhibited refusal and rejection of care; however, there was no documented evidence the facility revised the Comprehensive Care Plan to address the resident's refusal of care. Resident #114 had elevated blood glucose levels ([MEDICAL CONDITION]); however, there was no documented evidence the facility revised the Comprehensive Care Plan to address the resident's [MEDICAL CONDITION]. The findings include: Review of the facility's policy titled Care Plans - Comprehensive revised 03/18/15 revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Further review revealed the resident's comprehensive care plan is designed to: incorporate identified problem areas and incorporate risk factors associated with identified problems. Additionally the policy indicated the Care Planning/Interdisciplinary Team was responsible for the review and updating of the car plans including when there had been a significant change in the resident's condition. 1) Review of Resident #35 medical record revealed the facility admitted the resident on 02/17/16 with the [DIAGNOSES REDACTED]. Review of Resident #35's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident's Brief Interview for Mental Status to be thirteen (13) out of fifteen (15) indicating Resident #35's cognitive status was intact. Observation of Resident #35 on 12/05/18 at 9:00AM revealed the resident was refusing breakfast. Review of Resident #35's nurse's notes revealed a recent history of the resident refusing care and medications as follows: Nurse's notes dated 10/02/18 at 3:12PM stated resident will only take medication or allow care if he/she believes God wants him/her to; Nurse's notes dated 10/08/18 at 2:14 PM stated resident #35 was compliant with flu vaccine and antibiotic medication, but refused some of his other medications; Nurse's notes dated 10/15/18 at 12:55 AM stated Resident #35 refuses to go to bed; this is not normal behavior for this resident; Nurse's notes dated 10/19/18 at 6:11 AM stated Resident #35 was refusing to let Nursing Assistants State Registered (NASR)s change his/her brief and was refusing to take any medications; Nurse's notes dated 10/25/18 at 2:00 AM stated Resident #35's pants were wet but resident was refusing care and at 4:10 PM resident continues to refuse care; Nurse's notes dated 10/27/18 at 2:24 AM stated Resident #35 continues to refuse care and medications; Nurse's notes dated 10/31/18 at 4:51 PM stated Resident #35 continues refusal of by mouth medications, food, and fluids at times; Nurse's notes dated 11/13/18 at 2:41 PM stated Resident #35 continues to refuse medications at times, stating that he/she no longer needs them; Nurse's notes dated 12/04/18 at 2:47 PM stated Resident #35 refused breakfast and lunch; refused medications. Review of Resident #35's Comprehensive Care Plan, undated, no documented evidence the facility revised Resident #35's Care Plan to include the problem, goal and interventions to address his/her refusal of care, meals, medications and treatment. Interview with Nurse #7 on 12/06/18 at 9:30 AM revealed the behaviors Resident #35 was exhibiting and experiencing had been occurring for the past few months and during those months he/she had been refusing medications as well as some care. She stated the Resident was care planned for his/her delusional behaviors but no for his/her refusal of care. Interview with the Unit Manager on the unit in which Resident #35 resided, on 12/06/18 at 9:00 PM revealed Resident #35 just develop these behaviors within the past few months and the refusal of care, medications and treatments was something new within the last few months. She further stated the care plan should have been revised to include this problem and interventions developed to address the problem. Interview with the Director of Nursing (DON) on 12/06/18 at 10:00 AM revealed residents' care plan should reflect their current condition. She also stated refusal and rejection of care should be care planned and Resident #35's care plan should have been revised. Interview with the facility's Administrator on 12/06/18 at 9:45 AM revealed refusal and rejection of care should be care planned. 2) Review of the facility policy titled, Insulin Dependent Diabetic Resident Clinical Monitoring, dated 10/20/17, revealed licensed nurses would ensure routine and as needed (PRN) blood glucose monitoring of resident with insulin dependent diabetes. Continued review revealed licensed nurses would observe the resident for signs or symptoms of [MEDICAL CONDITION] (high blood glucose levels) and if symptoms were present, would inform the Medical Provider as well as document the following in Point Click Care: (1) the assessment; (2) the interventions; and (3) the evaluation of effectiveness. Further review revealed If the reading of a finger stick blood glucose was 401 or greater, staff would inform the Medical Provider via the secure communication in Point Click Care (PCC). Review of Resident #114's medical record revealed the facility admitted Resident #114 on 10/30/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum data Set (MDS) Assessment, dated 11/05/18, revealed the facility assessed Resident #114 as having a Brief Interview for Mental Status (BIMS) score of twelve (12 ) out of fifteen (15), indicating the resident was moderately cognitively impaired. Interview with Resident #114, on 12/04/18 at 10:15 AM, revealed he/she only received insulin once each daily, and no extra insulin was given. Continued interview revealed he/she expressed concern with knowing his/her blood sugar levels were too high, and he/she feels high in the clouds when his/her blood sugar is elevated. Further interview revealed he/she would like to know how to control the high blood sugars levels other than with diet. Review of Resident #114's Physician's order, dated 10/30/18, revealed a verbal order was given for Accu Checks (blood glucose monitoring) to be performed two (2) times each day for health maintenance related to Type Two (2) Diabetes Mellitus without complication. Review of Resident #114's Medication Administration Record [REDACTED]. Review of Resident #114's Comprehensive Care Plan, initiated on 11/02/18, identified a focus area of Diabetes Mellitus with a goal to have no complications related to diabetes throughout the review date. The facility implemented the intervention, dated 11/02/18 for diabetes medications as ordered by the doctor; however, there was no documented evidence the facility revised Resident #114's Care Plan to include monitoring the blood glucose levels and to notify the physician for the high or hyperglycemic levels to allow the physician to change or modify the diabetic medications per the resident's needs. Interview with Licensed Practical Nurse (LPN) #1, on 12/05/18 at 1:45 PM, revealed Resident #114's blood glucose levels do run high. Continued interview revealed the resident's care plan should reflect the resident to have elevated glucose levels with appropriate interventions in place so the care provided would be consistent and meet the resident's needs. Interview with(NAME)Unit Manager, on 12/05/18 at 2:15 PM, revealed the nurse checks the box in PCC to notify MD of the high blood glucose levels. Per interview, the comprehensive care plan should be resident centered to meet the resident's needs. Per interview, it was her expectation that the care plan be revised as needed to accurately reflect the resident's needs per the facility's policy. Interview with MDS Coordinator, on 12/05/18 at 2:30 PM, revealed Resident #114's care plan was not updated to reflect the resident's [MEDICAL CONDITION], and medication adjustments. Continued interview revealed the care plan addressed a general plan for diabetes and needed to be more specific to reflect the current care needs of the resident and to be resident centered. Interview with Director of Nursing (DON), on 12/06/18 at 10:56 AM, revealed the Comprehensive Care Plan reflects the residents' interventions and current clinical condition. Continue interview revealed the care plan should be revised as needed to provide consistent care to the resident to meet their needs. Per interview, it was her expectation the Comprehensive Care Plans would be devloped and updated/revised to meet the needs of the resident per the facility's policy. Interview with Administrator, on 12/06/18 at 10:45 AM, revealed it was his expectation for staff to follow the facility's policy related to care plans. Continued interview revealed the Comprehensive Care Plan should be updated and revised to address each resident's specific needs.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to provide treatment and care to one (1) of thirty-one (31) sampled residents (Resident #114). Resident #114 had elevated blood glucose levels on 11/16/18 and 11/18/18 that were not marked in the Point Click Care documentation system for the physician's timely notification to adjust the medication regimen. The findings include: Review of the facility policy titled, Insulin Dependent Diabetic Resident Clinical Monitoring, dated 10/20/17, revealed licensed nurses would ensure routine and as needed (PRN) blood glucose monitoring of resident with insulin dependent diabetes. Continued review revealed licensed nurses would observe the resident for signs or symptoms of [MEDICAL CONDITION] (high blood glucose levels) and if symptoms were present, would inform the Medical Provider as well as document the following in Point Click Care: (1) the assessment; (2) the interventions; and (3) the evaluation of effectiveness. Further review revealed If the reading of a finger stick blood glucose was 401 or greater, staff would inform the Medical Provider via the secure communication in Point Click Care (PCC). Review of the medical record revealed the facility admitted Resident #114 on 10/30/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum data Set (MDS) Assessment, dated 11/05/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of twelve (12 ) out of fifteen (15), indicating the resident was moderately cognitively impaired. Review of the Physician's order, dated 10/30/18, revealed a verbal order was given for Accu Checks (blood glucose monitoring) to be performed two (2) times each day for health maintenance related to Type Two (2) Diabetes Mellitus without complication. Review of the Medication Administration Record, [REDACTED]. Continued review revealed on 11/16/18 the resident's blood glucose level was three hundred thirty-four (334) at 7:00 AM, five hundred sixty-seven (567) at 11:30 AM and five hundred twenty-three (523) at 5:00 PM. Further review revealed on 11/18/18, the resident's blood glucose level was four hundred and ten (410) at 7:00 AM, HI at 11:30 AM and four hundred thirty-five (435) at 5:00 PM. Review of the Nursing Notes, dated 11/16/18, revealed no documented evidence the secure communication system in Point Click Care was activated to notify the physician of the elevated blood glucose readings, per the facility's policy. Review of the Point Click Care progress notes dated 11/16/18 and 11/18/18, revealed the box, to inform the Medical Provider via secure communication in Point Click Care, was not checked for the Medical Provider to be notified of the elevated blood glucose levels. There was no documented evidence the physician was notified of the elevated blood glucose readings, per the facility's policy. Review of the Nursing Note, dated 11/18/18 at 12:44 PM, and signed by Licensed Practical Nurse (LPN) #1, revealed Resident #114's blood glucose was checked two (2) times and read out to be HI each time. Per the note, there was no sign or symptoms of [MEDICAL CONDITION], insulin was given and the resident was encourage to drink water and eat a low sugar diet. There was no documented evidence the secure communication system in Point Click Care was activated to notify the physician of the elevated blood glucose readings, per the facility's policy. Interview with Resident #114, on 12/04/18 at 10:15 AM, revealed he/she only receives insulin once daily, and no extra insulin was given. Continued interview revealed he/she expressed concern with knowing his/her blood sugar levels were high, and he/she feels high in the clouds when the blood sugar is elevated. Further interview revealed he/she would like to know how to control the high blood sugars levels other than with diet. Interview with Licensed Practical Nurse (LPN) #1, on 12/05/18 at 1:45 PM, revealed Resident #114 was not a well-controlled diabetic at home prior to admission to the facility. Continued interview revealed Resident #114's blood glucose levels do run high and the process was to flag the information in Point Click Care (PCC) for the Medical Provider to review the blood sugar levels. Further interview revealed the Medical Doctor (MD) should be notified when a resident was symptomatic and the blood sugars were high; however, he was not aware of what the facility's policy was. Additional interview revealed he did not know why the high blood glucose levels were not flagged for the MD to review on 11/16/18 or 11/18/18. Interview with LPN #2, on 12/05/18 at 1:55 PM, revealed Resident #114 was a new admission and his/her blood glucose levels have been running high. Per interview, notification of the high levels was sent to the MD by checking the box in PCC and staff should call the MD when the resident was symptomatic and blood sugars are running high. Interview with(NAME)Unit Manager, Registered Nurse (RN), on 12/05/18 at 2:15 PM, revealed the nurse checks the box in PCC to notify MD of the high blood glucose levels. Per interview, it was her expectation that the box be check to notify the MD of the high levels to initiate medication changes as needed, per the facility policy. Interview with the Advance Practice Registered Nurse (APRN), on 12/06/18 at 10:45 AM, revealed she runs a twenty-four (24) hour daily report from the information entered into the PCC. Per interview, this report notifies her, when the notification box is checked, to review the elevated glucose levels so medications could be titrated in a timely manner. Per interview, if staff don't mark the box for the MD to review, it will not be on the report and she would not be notified to evaluate the elevated level and titrate or change the medications as the resident needed. Continued interview revealed it was her expectation that staff would call her for blood glucose levels above four hundred (400). Interview with Director of Nursing (DON), on 12/06/18 at 10:56 AM, revealed the facility policy states for blood glucose levels greater than four hundred (400), with symptoms, staff should call the Medical Provider. Continued interview revealed for asymptomatic residents with a high glucose level, staff should enter the information into PCC and check the box, which notifies the Medical Provider of the high level. Per interview, it was her expectation for staff to follow the facility's policy and mark the box in PCC to indicate the high glucose level so the physician would be alerted to the abnormal value to allow for any medication changes to be made in a timely manner. Interview with Administrator, on 12/06/18 at 10:45 AM, revealed his expectation was for staff to follow the policy to report high blood glucose levels to the Medical Provider so they could address the abnormal values for the health and well-being of the residents.

Based on interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure its abuse policy and procedures were implemented for one (1) of eight (8) sampled residents (Resident #1) Adult Protective Services (APS) notified the facility on 07/27/18 at approximately 2:00 PM, of an allegation of abuse involving Resident #1 and State Registered Nurse Aide (SRNA) #2. According to the allegation, during a struggle for the remote, Resident #1 grabbed #2's wrist and SRNA #2 hit Resident #1 in the groin to make the resident let go. During the facility's investigation it was recognized SRNA #1 overheard SRNA #2 tell Resident #1's spouse that she hit Resident #1 when the resident would not let go of her wrist; however, SRNA #1 did not immediately report this to supervisory/administrative staff. Additionally, there was no documented evidence the facility implemented their Abuse Policy related to reporting the allegation of abuse to State Agencies. (Refer to F-609) The findings include: Review of the facility's Kentucky Department of Veterans Affairs Abuse Policy and Procedures, dated (MONTH) (YEAR), revealed it was the goal of the facility to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, and misappropriation of property. Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish irrespective of any mental or physical condition. Types of abuse include verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Abuse also included deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Further review of the Policy, revealed it was the responsibility of the facility's employees, facility consultants, Attending Physician, family members, visitors, volunteers, and staff of other agencies, to immediately report any incident or suspected incident of neglect or abuse, including injuries of unknown source, and theft or misappropriation of resident property to their supervisor who in turn would notify the facility Administrator or Assistant Administrator. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of property, are reported immediately, but not later than two (2) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later that twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury to the Administrator and to other officials including State Survey Agency and Adult Protective Services. Further review of the Policy, revealed verbal/written notices to agencies will be made within two (2) hours of an occurrence involving abuse being reported. A written report of the findings of the investigation will be provided to the State Agencies within five (5) working days of the occurrence of the incident. Review of the facility's Investigation Report Form (untitled) dated 07/27/18 at 6:00 PM, and revised 08/17/18, completed by Registered Nurse (RN) #1/Supervisor, revealed on Friday 07/27/18, at approximately 2:00 PM, an Adult Protective Services (APS) worker visited the facility with an Anonymous Report which revealed an abuse allegation had been made with no date or time frame listed involving Resident #1, Licensed Practical Nurse (LPN) #4, State Registered Nurse Aide (SRNA) #2, and SRNA #3. The Report further revealed during the struggle for the remote, Resident #1 grabbed SRNA #2's wrist and although SRNA #2 yelled for help, the resident would not let go. Continued review revealed it was alleged SRNA #2 hit Resident #1 in the groin to make the resident let go. Further review of the Report, revealed immediately upon the facility hearing about the alleged abuse, records were reviewed and there was no documentation of the altercation. Staff involved were interviewed, and SRNA #2, alleged perpetrator, had already been transferred to another newly opened unit and the move was not related to any care issues. (Review of SRNA #2's time clock punches revealed the SRNA did not work 07/27/18, 07/28/18, and 07/29/18). According to the investigation, no injuries to Resident #1 were observed, and the resident was alert and ambulatory without assistance. However, further review of the Investigation Report Form and other reports submitted by the facility related to the investigation, revealed there was no documented evidence the facility notified the State Agencies of the allegation. Review of the Statement by Agency Staff SRNA #1, dated 08/16/18, untimed, revealed in a conversation between Resident #1s spouse, SRNA #1 and SRNA #2, the resident's spouse stated there was an incident with a remote that did not need to happen. Further review of the Statement, revealed the resident's spouse told SRNA #2 he/she was coming to SRNA #2 about hitting the resident between the legs. The Statement further revealed SRNA #2 then told the resident's spouse, Resident #1 grabbed her wrist and almost pulled her to bed so she had to hit him/her between the legs. The Statement did not reveal the date the conversation took place between the resident's spouse, SRNA #1 and SRNA #2. Interview on 08/10/18 at 8:48 AM, with SRNA #1/Agency Staff, who worked the 4:00 PM to 11:00 PM shift, and was assigned to Resident #1, revealed she did not work the night Resident #1 grabbed SRNA #2's wrist, but she was present the day Resident #1's spouse confronted SRNA #2 about the incident (date unknown). SRNA #1 revealed Resident #1's spouse came to the nurse's station and stated he/she was informed by Resident #1 that SRNA #2 hit the resident in the privates because the resident had grabbed her arm and wouldn't let go. SRNA #1 further revealed SRNA #2 told the resident's spouse she was trying to take the remote away from the resident when the resident grabbed her arm and yanked it. Additional interview revealed SRNA #2 told the resident's spouse she couldn't get away from the resident so she hit the resident in the privates and the resident let go of her arm. Continued interview with SRNA #1, revealed she did not report what she heard related to the conversation between SRNA #2 and the resident's spouse because she thought administrative staff were already aware of the incident and had notified the resident's spouse, since the resident's spouse brought up the concern. Post Survey phone interview on 08/13/18 at 1:18 PM, with RN #1/Supervisor, revealed the Administrator called her into his office on 07/27/18, and informed her APS had just visited the facility at 2:00 PM with an allegation of abuse. She stated the Administrator reviewed the allegation presented by APS with her and the Director of Nursing (DON). RN #1/Supervisor further stated she and the DON started conducting interviews with staff named in the allegation. Per interview, RN #1 and the DON interviewed SRNA #2 together and SRNA #2 could not remember the event in question and denied hitting the resident. RN #1 stated she conducted an interview with SRNA #1, who revealed when Resident #1's spouse confronted SRNA #2 at the nurse's station about hitting the resident in the private area, SRNA #2 admitted she hit the resident and this interview was included with other interviews submitted to the Administrator for review. Further interview with RN #1/Supervisor, revealed the Administrator was responsible for reporting abuse allegations to State Agencies and other officials. RN #1/Supervisor stated she was told abuse allegations didn't need to be reported if the facility unsubstantiated the allegations through the investigation process. Interview on 08/10/18 at 12:10 PM with the DON, revealed staff was expected to report any allegations of abuse to their supervisor, who would then notify the DON and the Administrator. Continued interview revealed when the Administrator was made aware of the allegation of abuse towards Resident #1, she was notified and an internal investigation was initiated immediately which included obtaining statements and interviewing staff who were involved in the allegation as well as Resident #1's spouse. The DON stated Resident #1 was not interviewed during the investigation, related to his/her disorganized thought processes. Further interview revealed after the interviews and statements were obtained, she reviewed them with the Administrator and it was recognized SRNA #1 should have immediately reported she overheard a conversation between Resident #1's spouse and SRNA #2, which revealed SRNA #2 admitted hitting Resident #1 (date unknown). Additional interview with the DON, revealed after the internal investigation was complete, and all evidence was evaluated, the allegation was unsubstantiated. She stated it was the Administrator's decision to report the allegation to State Agencies; however, the allegation may not be reported to State Agencies if the facility did not substantiate the allegation. The DON stated the facility did not interpret the regulation as requiring all allegations of abuse to be reported to State Agencies within two (2) hours. However, after reviewing the facility's Abuse policies and protocol, the DON stated the State Agencies should have been notified of the abuse allegation involving Resident #1 within two (2) hours of the facility being made aware of the abuse allegation, and a follow up report should have sent to the State Agencies within five (5) working days. Interview on 08/10/18 at 12:35 PM, and post survey phone interview on 8/24/18 at 10:55 AM with the Administrator, revealed once the facility was made aware of the allegation of abuse related to Resident #1, an internal investigation was immediately conducted. Per interview, the DON ensured interviews or statements were obtained from all staff involved and SRNA #2 was notified by phone on 07/27/18, that she was not to come to work pending the investigation. The Administrator stated the investigation related to Resident #1 was concluded on 7/27/18, although there were some interviews obtained after that date. Per interview, during the investigation, it was recognized SRNA #1 did not report to administrative staff overhearing SRNA #2, tell Resident #1's spouse she hit Resident #1 because the resident would not let go of her wrist. He revealed SRNA #1 should have immediately reported this. Further interview with the Administrator, revealed interview conducted with SRNA #4 on 07/27/18, revealed she was in the room as a witness when Resident #1 grabbed SRNA #2's arm and confirmed there was no hitting or mistreatment by SRNA #2. The Administrator stated after listening to statements, reconstructing the event, and talking to those involved, the facility unsubstantiated the allegation and therefore did not report the allegation to State Agencies. He stated the facility only reported allegations of abuse to State Agencies when the facility substantiated the allegation through the internal investigation. Per interview, when he reviewed the regulations related to abuse, he did not interpret the regulation as meaning all suspected abuse allegations needed to be reported to State Agencies.

Based on interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure all alleged violations involving abuse are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse, to the Administrator and to State Agencies per State Law for one (1) of eight (8) sampled residents (Resident #1). On 07/27/18, at approximately 2:00 PM, the Administrator received an Anonymous Report from the Adult Protective Services (APS) worker who was visiting the facility, which alleged during a struggle for the remote, Resident #1 grabbed State Registered Nurse Aide (SRNA) #2's wrist and would not let go. Per the allegation, SRNA #2 hit Resident #1 in the groin to make the resident let go. During the facility's investigation it was identified SRNA #1 overheard SRNA #2 tell Resident #1's spouse that she hit Resident #1 when the resident would not let go of her wrist; however, SRNA #1 did not report this to supervisory staff or to the Administrator. In addition, there was no documented evidence the facility reported the allegation to State Agencies. (Refer to F-607) The findings include: Review of the facility's Kentucky Department of Veterans Affairs Abuse Policy and Procedures, dated (MONTH) (YEAR), revealed it was the responsibility of the facility's employees, facility consultants, Attending Physician, family members, visitors, volunteers, and staff of other agencies, to immediately report any incident or suspected incident of neglect or abuse, including injuries of unknown source, and theft or misappropriation of resident property to their supervisor who in turn would notify the facility Administrator or Assistant Administrator. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of property, are reported immediately, but not later than two (2) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later that twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury to the Administrator and to other officials including State Survey Agency and Adult Protective Services. Further review of the Policy, revealed verbal/written notices to agencies will be made within two (2) hours of an occurrence involving abuse being reported. A written report of the findings of the investigation will be provided to the State Agencies within five (5) working days of the occurrence of the incident. Review of the facility's Investigation Report Form (untitled) dated 07/27/18 at 6:00 PM, and revised 08/17/18, completed by Registered Nurse (RN) #1/Supervisor, revealed at approximately 2:00 PM on Friday 07/27/18, an Adult Protective Services (APS) worker visited the facility with an Anonymous Report which revealed an abuse allegation had been made with no date or time frame listed involving Resident #1, Licensed Practical Nurse (LPN) #4, State Registered Nurse Aide (SRNA) #2, and SRNA #3. The Report revealed during the struggle for the remote, the resident grabbed SRNA #2's wrist and although SRNA #2 yelled for help, the resident would not let go. Further review revealed it was alleged SRNA #2 hit Resident #1 in the groin to make the resident let go. Continued review of the Report, revealed immediately upon the facility hearing about the alleged abuse, records were reviewed and there was no documentation of the altercation. Staff involved were interviewed, and SRNA #2 had already been transferred to another newly opened unit and the move was not related to any care issues. (Review of the time clock punches for SRNA #2, revealed the SRNA did not work 07/27/18, 07/28/18, and 07/29/18). Per the investigation, no injuries to Resident #1 were observed, and the resident was alert and ambulatory without assistance. However, further review of the Investigation Report Form and other reports submitted by the facility related to the investigation, revealed there was no documented evidence the State Agencies were notified of the allegation. Review of the facility's documented interview with Resident #1's spouse, dated 07/30/18, revealed he/she visited the resident back in (MONTH) or (MONTH) and the resident told the spouse he/she got beat up by three (3) women the night before; and they were trying to take the remote. Further review revealed the resident's spouse stated he/she then decided to do his/her own detective work. Additional review revealed the resident's spouse stated SRNA #1 and SRNA #2 were at the nurse's station (date unknown) when the resident's spouse told SRNA #1 and SRNA #2 he/she thought there was a struggle with Resident #1 over a remote and Resident #1 grabbed SRNA #2 by the wrist; SRNA #4 was called over to help; and SRNA #2 had to hit the resident in the legs to get him/her to let go. Continued review revealed the spouse stated while he/she was describing the scenario, SRNA #2 stood there and nodded her head while listening and the spouse took this as SRNA #2 admitting that the story was true. Interview on 08/08/18 at 2:15 PM, with Resident #1's spouse, revealed she visited Resident #1 every day and on one of the visits in June, the resident informed the spouse that three (3) staff members had beat him/her up the night before and the resident requested to be taken home. Continued interview revealed the spouse went to the nurse's station where SRNA #1 and SRNA #2 were standing and questioned the SRNAs about the incident (date unknown). Per interview, SRNA #2 stated while providing care to the resident, he/she grabbed her wrist and she had to yell for help. Continued interview revealed SRNA #2 told the spouse she had to hit the resident in the privates in order for the resident to let go. Resident #1's spouse further stated, a week or so later, she was called into the Administrator's office where she was confronted about the incident by the Administrator and the Director of Nursing (DON) and they addressed her concerns regarding the abuse allegation. Interview was attempted with Resident #1, on 08/09/18 at 4:00 PM; however, the resident did not respond to the State Agency Representative's questions. Review of the Statement by Agency Staff SRNA #1, dated 08/16/18, untimed, revealed in a conversation between Resident #1s spouse, SRNA #1 and SRNA #2, the resident's spouse revealed there was an incident with a remote that did not need to happen. Per the Statement, the resident's spouse told SRNA #2 he/she was coming to SRNA #2 about hitting the resident between the legs. The Statement revealed SRNA #2 then told the resident's spouse, Resident #1 grabbed her wrist and almost pulled her to bed so she had to hit him/her between the legs. The Statement did not reveal when the conversation took place between the resident's spouse, SRNA #1 and SRNA #2. Interview on 08/10/18 at 8:48 AM, with SRNA #1/Agency Staff, who worked the 4:00 PM to 11:00 PM shift, and was assigned to Resident #1, revealed she was not working the night Resident #1 grabbed SRNA #2's wrist, but she was present the day Resident #1's spouse confronted SRNA #2 about the incident (date unknown). SRNA #1 stated Resident #1's spouse came to the nurse's station and revealed he/she was informed by Resident #1 that SRNA #2 hit the resident in the privates because the resident had grabbed her arm and wouldn't let go. SRNA #1 further stated SRNA #2 told the resident's spouse she was trying to take the remote away from the resident when the resident grabbed her arm and yanked it. Per interview, SRNA #2 told the resident's spouse she couldn't get away from the resident so she hit the resident in the privates and the resident let go of her arm. Additional interview with SRNA #1, revealed she did not report what she heard related to the conversation between SRNA #2 and the resident's spouse because she thought administrative staff were already aware of the incident and had notified the resident's spouse, since the resident's spouse brought up the concern. She stated on a later date, maybe a few weeks later, she was pulled into an office by RN #1/Supervisor, and was asked about the situation. SRNA #1 stated she told RN #1/Supervisor she wasn't working the night SRNA #2 allegedly hit the resident, but she was working the night Resident #1's spouse confronted SRNA #2 and conveyed what she heard during the conversation between SRNA #2 and Resident #1's spouse. SRNA #1 stated RN #1/Supervisor asked her to write a statement of what occurred. Review of the facility's documented interview dated 07/27/18 at 4:46 PM, with SRNA #2, the alleged perpetrator, revealed she did not remember a time involving a remote, but did remember a time a few months ago when Resident #1 grabbed her wrist. Per the interview, SRNA #4 was able to calm the resident and he/she let go. Further review of the interview, revealed she had never hit the resident. Interview on 08/10/18 at 9:03 AM, with SRNA #2, the alleged perpetrator, who was named in the abuse allegation, revealed she worked the 7:00 PM to 7:00 AM shift and was familiar with Resident #1. SRNA #2 revealed she could not recall an incident where Resident #1 grabbed her arm and she further denied hitting the resident in the groin in order for the resident to let go of her wrist. Per interview, she did recall having a conversation with Resident #1's spouse about taking the resident's remote, but she did not recall the resident's spouse questioning her about hitting the resident in the groin. Continued interview revealed she was interviewed by RN #1 and the DON related to the allegation. Review of the facility's documented interview with SRNA #3, dated 07/27/17 at 5:00 PM, revealed there were no instances she recalled of struggles between SRNA #2 and Resident #1. The State Agency Representative attempted a phone interview on 08/10/18 at 9:00 AM, with SRNA #3, who was named in the allegation presented by APS; however, the phone numbers submitted by the facility for SRNA #3 were not working numbers. Review of the facility's documented interview with SRNA #4, on 07/27/18 at 4:50 PM, revealed she did not remember any specific events related to Resident #1 and SRNA #2. Per the interview, staff had to be careful how they approached the resident due to his/her behaviors. Further review revealed she had never seen SRNA #2 hit anyone. Post Survey phone interview, on 08/24/18 at 11:22 AM, with SRNA #4, revealed she had seen Resident #1 grab SRNA #2's wrist while she was in the room with the resident, but SRNA #2 remained calm, and did not mistreat the resident in any way. Per interview, at the same time a remote fell out of the resident's blanket and she (SRNA #4) picked it up and put it on the bedside table. She further stated there was no struggle with the resident related to the remote. Review of the facility's documented interview with LPN #4, dated 07/27/18 at 4:50 PM, revealed she did not recall and was not involved in any situation as described in the allegation. Interview on 08/10/18 at 11:13 AM, with LPN #4, who worked the 7:00 PM to 7:00 AM shift, and was named in the abuse allegation presented by APS, revealed she was not aware of an incident involving SRNA #2 hitting Resident #1 in the private area. She stated she was interviewed by administrative staff related to this, but she had no knowledge of the incident. Post Survey phone interview on 08/13/18 at 1:18 PM, with RN #1/Supervisor, revealed the Administrator called her into his office on 07/27/18, and told her APS had just visited the facility at 2:00 PM with an allegation of abuse. Per interview, the Administrator reviewed the allegation presented by APS with her and the DON. RN #1/Supervisor stated she and the DON then reviewed the documentation in Resident #1's medical record; however, there was no documentation in the record related to the incident. RN #1 further stated she conducted a brief assessment of Resident #1 with no concerns noted, but did not interview the resident because she did not consider the resident to be interviewable. RN #1/Supervisor further stated she and the DON started conducting interviews with staff named in the allegation. Further interview with RN #1/Supervisor, revealed she and the DON interviewed SRNA #2 together and SRNA #2 could not recall the event in question and denied hitting the resident. RN #1 stated she conducted an interview with SRNA #1, who stated when Resident #1's spouse confronted SRNA #2 at the nurse's station about hitting the resident in the private area, SRNA #2 admitted she hit the resident and this interview was included with all the other interviews submitted to the Administrator for review. Additional interview with RN #1/Supervisor, revealed the Administrator was to be immediately notified of any allegations of abuse and the Administrator was responsible for reporting abuse allegations to State Agencies and other officials. Further interview revealed she was told abuse allegations didn't need to be reported to State Agencies if the facility unsubstantiated the allegations through the investigation process. Interview on 08/10/18 at 12:10 PM with the DON, revealed staff were to report any allegations of abuse to their supervisor, who would then notify the DON and the Administrator. Further interview revealed when the Administrator was made aware of the allegation of abuse towards Resident #1, she was notified and an internal investigation was initiated immediately which included obtaining statements and interviewing staff who were involved in the allegation as well as Resident #1's spouse. The DON revealed Resident #1 was not interviewed during the investigation, related to his/her disorganized thought processes. Continued interview revealed after the interviews and statements were obtained, she reviewed them with the Administrator and it was identified SRNA #1 should have reported to administrative staff that she overheard SRNA #2 state she hit Resident #1 during conversation with Resident #1's spouse (date unknown). Further interview with the DON, revealed after all interviews and evidence were analyzed the allegation was unsubstantiated. Per interview, after the internal investigation was complete, it was the Administrator's decision to report the allegation to State Agencies; however, the allegation may not be reported to State Agencies if the facility did not substantiate the allegation. The DON stated the facility did not interpret the regulation as requiring all allegations of abuse to be reported to State Agencies within two (2) hours. However, after reviewing the facility's Abuse policies and protocol, the DON stated the State Agencies should have been notified of the abuse allegation involving Resident #1 within two (2) hours of the facility being made aware of the abuse allegation, and a follow up report should have sent to the State Agencies within five (5) working days. Interview on 08/10/18 at 12:35 PM, and post survey phone interview on 8/24/18 at 10:55 AM with the Administrator, revealed once the facility was made aware of the allegation of abuse related to Resident #1, an internal investigation was immediately conducted. Per interview, the DON ensured interviews or statements were obtained from all staff involved and SRNA #2 was notified by phone on 07/27/18, that she was not to come to work pending the investigation. The Administrator stated the investigation related to Resident #1 was concluded on 7/27/18, although there were some interviews obtained after that date. He stated during the investigation, it was recognized SRNA #1 did not report to administrative staff overhearing SRNA #2, tell Resident #1's spouse she hit Resident #1 because the resident would not let go of her wrist (date unknown). Per interview, SRNA #1 should have immediately reported this to supervisory staff. Further interview with the Administrator, revealed interview with SRNA #4 on 07/27/18, revealed she was in the room as a witness when Resident #1 grabbed SRNA #2's arm and confirmed there was no hitting or mistreatment by SRNA #2. He further stated after listening to statements, reconstructing the event, and talking to those involved, the facility unsubstantiated the allegation and therefore did not report the allegation to State Agencies. Per interview, the facility staff was to notify the Administrator of all allegations of abuse immediately, but the facility only reported allegations of abuse to State Agencies when the facility substantiated the allegation through the internal investigation. The Administrator stated when he reviewed the regulations related to abuse, he did not interpret the regulation as meaning all suspected abuse allegations needed to be reported to State Agencies.

Based on observation, interview, record review and review of the facility Policy, it was determined the facility failed to provide comfortable temperature levels, between seventy-one (71) degrees to eighty-one (81) degrees Fahrenheit (F), in resident common dining room areas, for four (4) of twenty-five (25) sampled residents (Residents #3, #11, #12 and #17) and four (4) Unsampled residents (Unsampled Residents A, C, F, and G). A Quality of Life Assessment Group Interview, conducted by the State Agency Representative with resident representatives of the Resident Council on 10/18/17 from 11:00 AM until 11:50 AM, revealed five (5) out of ten (10) residents who attended the meeting voiced the dining rooms in the facility were too cold. The residents in the Group Interview who complained of cold dining room temperatures included Resident #3, Resident #12, and Unsampled Residents A, C, and F and these residents were served meals in the Washington dining room, and the combined Roosevelt/Lincoln Units dining room. The Jefferson Dementia Unit was not represented in the Group. Also, interviews on 10/19/17 with Resident #11, Resident #17, and Unsampled Resident G who did not attend the Group Interview on 10/18/17, complained of cold dining rooms temperatures. In addition, observation on 10/19/17, from 8:20 AM until 9:45 AM, revealed temperatures obtained utilizing the EXTECH Laser Thermometer, obtained from the Office of Inspector General's (OIG) Office, revealed ambient room temperatures in all dining rooms including the Washington Unit dining room, the dining room shared by the Roosevelt and Lincoln Units, and the Jefferson Unit dining room had areas that registered less than seventy-one (71) degrees Fahrenheit. The findings include: Review of the facility's Policy titled, Quality of Life-Homelike Environment, revised August 2009, revealed residents were provided with a safe, clean, comfortable and homelike environment. Per Policy, the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Further review of the Policy, revealed these characteristics included comfortable temperatures. 1. Review of the Resident Council Meeting Minutes, dated 04/20/17, 05/26/17, 06/21/17, 07/19/17, 08/16/17, and 09/26/17, revealed there were no documented resident complaints about resident room or dining room temperatures. However, during the Quality of Life Assessment Group Interview, conducted by the State Agency Representative with residents of the Resident Council on 10/18/17 from 11:00 AM until 11:50 AM, residents voiced complaints of cold temperatures in the dining rooms including Resident #3, Resident #12, Unsampled Resident A, Unsampled Resident C and Unsampled Resident F. A. Resident #3 was assessed by the facility on the Significant Change Minimum Data Set (MDS), dated [DATE], to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Interview with Resident #3 during the Group Interview, revealed the dining rooms were too cold. Resident #3 stated he/she had even left the dining room without finishing meals because it was too cold. Follow up interview with Resident #3, on 10/19/17 at 8:55 AM, revealed the resident ate meals in the Washington Unit dining room, and at least two (2) times in the last two (2) years he/she had left the dining room without finishing a meal because the room temperature was too cold. The resident further stated, he/she left the dining room only two (2) times because I like to eat, so I just tough it out. Further interview revealed the resident had complained to the nurses, who would sometimes call maintenance and have the dining room warmed up, but the next day it was cold again. The resident further stated, the nurses want it cool to keep the germs down; that's what they've told me. In addition, Resident #3 suggested his/her roommate, (Unsampled Resident G), be interviewed because he/she constantly complained about freezing in the dining room during meals. B. Unsampled Resident A was assessed by the facility on the Quarterly (MDS), dated [DATE], to have a BIMS score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Interview with Unsampled Resident A during the Group interview, revealed the dining room was too cold during meal service. Further interview revealed during the facility's regular Resident Council Meetings, the residents had not been questioned about dining room temperatures Follow up interview with Unsampled Resident A, on 10/19/17 at 9:10 AM, revealed the resident ate meals in the Washington Unit dining room, and he/she felt it was too cold, and so did a lot of the other residents. Per interview, Unsampled Resident A had never complained about the cold temperatures to the nursing staff. C. Unsampled Resident C was assessed by the facility on a Quarterly MDS Assessment, dated 10/03/17, as having a BIMS score of eleven (11) out of fifteen (15), which indicated the resident was moderately cognitively impaired. Interview with the resident during Group Interview revealed the Washington dining room was very cold. Follow up interview with Unsampled Resident C, on 10/19/17 at 9:15 AM, revealed the resident was admitted in the middle of July and had worn the red jacket he/she was currently wearing ever since. The resident further stated, if I didn't have it on, I would freeze. Continued interview revealed the resident ate meals in the Washington Unit dining room, and he/she had asked the waitresses (nursing staff) about the dining room being so cold. Per interview, they told him/her it was for health reasons. The resident further stated, almost everybody eats in their jackets because they are cold too. D. Unsampled Resident F was assessed by the facility on the Quarterly MDS Assessment, dated 08/28/17, to have a BIMS score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Interview with the resident, during the Group Interview, revealed the Roosevelt and Lincoln combined dining room was cold, but it was even colder at the tables under the ceiling vent. Follow up interview with Unsampled Resident F, on 10/19/17 at 9:50 AM, revealed the resident ate meals in the Roosevelt/Lincoln Units dining room three (3) times a day. The resident further stated he/she was cold-natured and wore a jacket all day long. The resident stated he/she also noticed a lot of the other residents wore jackets during meals. Per interview, it was really cold at the tables under the ceiling vents where the air blows down. Continued interview revealed the resident had not said anything to anybody about being cold because he/she would not be at the facility long. Further interview revealed the resident wasn't sure who to complain to about the cold dining room temperatures until the question was asked yesterday in the meeting (Group Interview). E. Resident #12 was assessed by the facility on the Quarterly MDS Assessment, dated 09/07/17, as having a BIMS score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Interview with the resident during Group Interview revealed the Roosevelt/Lincoln shared dining room was always cold. Follow up Interview with Resident #12, on 10/19/17 at 9:55 AM, revealed the resident usually ate meals in the Roosevelt/Lincoln Units dining room. Continued interview revealed he/she was always cold except in his/her room. Per interview the dining room was always cold, and he/she had to wear a jacket. The resident further stated he/she loved to be warm, and had begged the maintenance man to leave his/her bedroom warm, which he did. 2. Temperatures of ambient dining room temperatures using the EXTECH IR (Infra-red) Type K Thermocouple Input Thermometer from the OIG's office, were obtained by the State Agency Representative which revealed the dining room temperatures were not consistent throughout the room and areas of the dining rooms had temperatures below seventy-one (71) degrees F. Observation of the Washington Unit dining room, on 10/19/17 at 8:20 AM, revealed the temperature reading at table #1 (entry table by the Television) was 70.6 F; temperature reading at table #2 was 69.8 F; temperature reading at table #3 was 72.8 F; temperature reading at table #4 (by the clock in the middle section of the room) was 75.3 F; temperature reading at table #5 was 75.7 F; temperature reading at table #6 (by the piano) was 75.5 F, and the temperature reading at table #7 (the assisted eating table) was 71.4 F. Observation of the Jefferson Unit dining room, on 10/19/17 at 8:30 AM, revealed the temperature reading at table #1 (entry table by the Television) was 70.8 F; temperature reading at table #2 was 75.5 F; temperature reading at table #3 was 74.8 F; temperature reading at table #4 was 74 F; and the temperature reading at table #5 (next to the window and piano) was 69.8 F. Observation of the shared Roosevelt/Lincoln Units dining room, on 10/19/17 at 9:30 AM, revealed the temperature reading at table #1 (entry table by the Television) was 73.2 F; temperature reading at table #2 was 72.4 F; temperature reading at table #3 (by the clock) was 67.8 F; temperature reading at table #4 (by the oxygen door) was 67.1 F; and the temperature reading at table #5 (next to the door by the nurses' station) was 72.8 F. 3. Resident #17 was assessed by the facility on an Annual MDS Assessment, dated 08/29/17, as having a BIMS score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Interview with Resident #17 on 10/19/17 at 11:02 AM, revealed the resident had breakfast in the Lincoln dining room approximately three (3) days a week, and always had to wear a jacket to breakfast because the dining room was always cold. Continued interview revealed the resident had never informed the staff of his/her concerns. 4. Resident #11 was assessed by the facility on a Quarterly MDS assessment dated [DATE], as having a BIMS score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Observation of Resident #11, on 10/19/17 at 11:30 AM, in the Washington Unit dining room, revealed the resident was dressed in a sweat shirt and sweat pants. Interview with the resident at the time of observation, revealed he/she had been at the facility for three (3) years, and he/she always wore a jacket or sweat clothes in the Washington Unit dining room because it was always cold. Continued interview revealed the resident had told the nurses, but did not feel it had made a difference. The resident further stated they kept seating him/her under the ceiling vents and it was cold there. 5. Unsampled Resident G was assessed by the facility on an Annual MDS, dated [DATE], as having a BIMS score of seven (07) out of fifteen (15), which indicated the resident was severely cognitively impaired. Observation of Unsampled Resident G on 10/19/17 at 9:45 AM, revealed the resident was in bed with a quilted blanket partially covering the resident from the waist down. The resident wore a heavy black leather jacket zipped almost all the way up, a sweatshirt under the jacket, black flannel-type gloves on both hands, jean pants, socks and shoes. Interview with the resident at the time of observation, revealed the resident was oriented to self, knew the name of the facility in which he/she resided, and did not appear to have confusion during conversation. Unsampled Resident G stated the Washington dining room was cold. The resident further stated that was why he/she came straight to his/her room after the meal and got under the covers to get warm. Further interview revealed there was nothing wrong with the food, but it's hard to enjoy it when you're freezing. Continued interview revealed, the people are great, but dog-gone it, it's cold. Per interview, he/she had talked to the waitresses and dietary people, in the past and they called maintenance to increase the dining room temperature, but it was still cold. Additional interview revealed his/her roommate who had been at the facility longer knew how to get things done and knew who to talk to, but also had no luck in getting the dining room warmed up. Interview with State Registered Nurse Aide #1 (SRNA), on 10/18/17 at 12:15 PM, and 2:00 PM, revealed the Jefferson (Dementia) Locked Unit dining room was usually cold, and not just at certain times of the year. She stated the residents needed the dining room to be warmer, and it should be about the resident's comfort and not the staff's comfort. She further stated they had to provide the residents with blankets in the dining room to keep them warm. Continued interview revealed when maintenance turned the heat up in the dining room, the resident's took the blankets off. Interview with SRNA #2, on 10/18/17 at 4:00 PM, revealed the Jefferson Locked Unit dining room was sometimes cold. Per interview, staff would dress the residents warm, and provide extra blankets when the temperature was cold. Interview with SRNAs #3, #4, and #5, on 10/19/17 at 10:10 AM, revealed they had never heard any residents complain about the shared Roosevelt/ Lincoln Unit dining room being cold, and they did not perceive the dining room as cold. However, all three (3) SRNAs agreed they had noticed residents never sat at the table by the TV, and they thought it was because there was a vent directly above that table which blew out cold air. Interview with the Activities Director, on 10/19/17 at 11:25 AM, revealed if a resident complained about the temperature in their room, or the dining room, the nurse would tell the Ward Clerk who would call maintenance and put in a Work Order for the temperature to be adjusted. Continued interview revealed she could not recall any concerns or complaints about the dining room being too cold. However, she stated since the facility had the new air unit placed, there seemed to be a big difference with temperature variations in the building. Interview with the Recreation Aide, on 10/19/17 at 11:30 AM, revealed she took the minutes during Resident Council Meetings, and she did not recall any complaints about the dining room temperatures. Post-Survey phone interviews with Ward Clerk #1 from Jefferson (Dementia) Unit on 10/23/17 at 12:20 PM; Ward Clerk #2 from Roosevelt Unit at 12:25 PM; Ward Clerk #3 from Lincoln Unit at 12:30 PM; and Ward Clerk #4 from Washington Unit at 12:35 PM; revealed when a resident complained about their room temperature, or the dining room temperature, the nurses would inform the Ward Clerks. Further interview, revealed the Ward Clerks would send a Work Order through the computer system to maintenance. Per interview, maintenance would then check the temperature from the computer downstairs, or sometimes with a temperature gun on the Unit, and make adjustments. Continued interview revealed the nurses also had the option to call down to security, who would relay the message to maintenance after hours or on weekends, when a resident complained about the air temperature. Further interview revealed the Ward Clerks did not recall any recent complaints about the dining room temperatures. Post-Survey phone interviews conducted on 10/23/17, with Licensed Practical Nurse (LPN) #1 from Jefferson (Dementia) Unit at 12:22 PM; Registered Nurse (RN) #1 from Roosevelt Unit at 12:27 PM; LPN #2 from Lincoln Unit at 12:33 PM; and LPN #3 from Washington Unit at 12:40 PM; all revealed if a resident complained about their room, or the dining room, a Work Order was sent to maintenance by the Ward Clerk through the computer. Further interview revealed the nurses could also call maintenance directly through security on the phone, and request the temperature to be checked. Continued interview revealed if there was a temperature concern they would offer blankets or jackets to the residents if they were cold; offer to relocate them to a different location in the dining room; or if it was an issue with their room, they would relocate them to a different room. Additional interview revealed they did not remember any recent complaints about the dining room temperatures being too cold. Interview with the Maintenance Director, on 10/19/17 at 8:50 AM, revealed he had been employed at the facility for two (2) years and the facility did not have any equipment to manually check room air temperatures. Per interview, there were no laser thermometers and they did not perform routine or periodic checks of air temperatures. Continued interview revealed the facility's heating and cooling system was controlled by a computer in the maintenance room in the basement, and adjustments were made to room temperatures throughout the facility per the computer. Further interview revealed the computer could not generate a report to show what the room temperature readings had been, and would only show the current reading on the screen at any given time. Additional interview revealed if a resident complained about the temperature of their room, or the dining room, the nurse would call down and tell maintenance staff, and they would increase or decrease the temperature through adjustments in the computer. He further stated if the residents complained it was too cold, and the temperature was increased, the nurses would complain it was too hot, and this was ongoing. Interview with Maintenance Technician #1, on 10/19/17 at 11:40 AM, revealed he had a laser gun on his cart which he used to check room temperatures when the maintenance department received a Work Order about a complaint of a room being too hot or too cold. Continued interview revealed he worked at the facility as a technician for seven (7) years, but was also a licensed HVAC (heating, ventilation, and air conditioning) contractor. He stated the facility did not have a preventative HVAC program, so routine or periodic checks were not done. However, per interview routine checks used to be completed on the HVAC in the past, before the facility installed the new energy-efficient heat pumps, with energy exchange wheels, sensors, and computer-based controllers. He stated the thermostats on the walls were bypassed by the computer. Further interview revealed the computer displayed all areas of the building, room by room. Per interview, a temperature range was set in the computer and when the room temperature dropped down below, or rose above the settings, the system automatically adjusted from heat to cool mode to maintain the temperature within the selected range. Observation of the computer system with Maintenance Technician #1, on 10/19/17 at 11:45 AM, in the maintenance room, revealed all the dining rooms were set for temperature range of 74-77 degrees F. Continued observation revealed Dining room [ROOM NUMBER]'s current temperature read 74 degrees F, Dining room [ROOM NUMBER]'s read 74 degrees F, Dining room [ROOM NUMBER] did not display a current temperature, and Dining room [ROOM NUMBER] displayed 75 degrees F. Additional interview with the Maintenance Technician, during the observation revealed the computer system had never really worked right. He stated sometimes the readings would come up; and sometimes the readings would partially come up. Per interview, there would be temperature variations causing the system to need to be adjusted and reset. He further stated when there was a question about a temperature, he would check the area manually with the thermometer gun which per observation was was a Milwaukee Infra-red Thermometer Gun. However, per interview, he did not document the temperature readings he obtained manually. He also stated according to the computer display screen, the temperature range settings had all been reset this morning, and there was no way to tell the past history of the settings or temperatures. Maintenance Technician #1 revealed it was almost impossible to maintain a constant temperature, even within sections of the same dining room. Interview with the Director of Nursing (DON), on 10/19/17 at 12:30 PM, revealed if there were complaints from residents about room temperatures being too hot or too cold, nursing staff would place a Work Order and maintenance would make the needed adjustments. Continued interview revealed during business hours Monday through Friday, the nurse would tell the Ward Clerk, and the Ward Clark would call maintenance. She further stated if it was after-hours or on the weekends, the house supervisor would make the call to maintenance. Additional interview revealed nursing staff should ensure the residents were comfortable and if there was a concern related to air temperatures, the nurse's should follow up with Maintenance staff to ensure temperatures were in range. Interview with the Administrator, on 10/19/17 at 12:45 PM, revealed the new heating and cooling system was installed prior to him becoming the Administrator. He stated he was led to believe the software program automatically adjusted the room temperature to the ranges specified and programmed. He further stated there were huge sensors throughout the HVAC system, and the wall thermometers in the facility rooms no longer worked. Continued interview revealed he was not aware they were not able to capture the computer screen display, or print a historical report, of the current or past room temperature readings in the facility. Further interview revealed he did not ask for daily reports of the room temperatures to be printed out, and he was not aware there was no tracking system in place. Additional interview revealed it was his expectation for the facility to be in compliance with the regulation and temperature should range from seventy-one (71) to eight (80) degrees F in the residents' dining areas. He further stated he would contact the HVAC supplier to see if the computer software program could generate a historical report, or retrieve a data graph of recordings of the temperature readings to ensure compliance.

Based on interview, record review, and review of facility policy, it was determined the facility failed to implement their written policies and procedures that prohibit abuse of residents. The facility failed to ensure all alleged violations involving abuse were reported immediately to Administration, and failed to protect the residents after an allegation of abuse was witnessed for one (1) of six (6) sampled residents. (Resident #1). A staff member witnessed State Registered Nurse Aide (SRNA) #5, to cover Resident #1's mouth with her hand due to the resident making noise, on 10/09/16 at approximately 4:20 AM; however, the incident was not reported to the House Charge Nurse, until 6:14 AM, and SRNA #5 was allowed to continue to work in resident care areas until approximately 6:40 AM. The findings include: Review of the facility's Prevention of Abuse, Neglect, And Misappropriation In Veterans Nursing Home Policy, dated 03/11/10, revealed each resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. Continued review of the policy, revealed each facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of residents. Review of the facility's Reporting Abuse To Facility Management Policy, dated 10/23/15, revealed it was the responsibility of the facility's employees to immediately report any incident or suspected incident of neglect or resident abuse to the administrator or his/her designee. Review of Resident #1's medical record revealed the facility admitted the resident on 05/11/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/15/16, revealed the facility assessed the resident's cognitive level as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15). Review of the facility's Investigation, revealed on 10/09/16, at approximately 4:30 AM, Resident #1 was yelling and SRNA #6 Nursing went to check on the resident and discovered the resident had removed his/her brief and had an incontinent episode. Continued review revealed SRNA #6 asked SRNA #5 to assist her with the care of Resident #1. Further review of the Investigation revealed SRNA #6 stated SRNA #5 commented to her the resident was yelling out and she was afraid the resident would wake up his/her roommate. Per the investigation, SRNA #6 turned away from the resident to obtain supplies and when she turned back around, she observed SRNA #5 with her hand covering Resident #1's mouth and the resident was attempting to remove SRNA #5's hand. Continued review of the Investigation, revealed SRNA #6 verbally corrected SRNA #5, who then removed her hand and apologized for her actions. Per the Investigation the House Charge Nurse was notified by LPN #3, and the House Charge completed a skin assessment for Resident #1, and notified the Assistant Director of Nursing (ADON) and Assistant Administrator of the allegation. Further review, revealed SRNA #5 was removed from direct resident care and the Agency was contacted and informed SRNA #5 was not to return to the facility. Review of the Statement written by the House Charge Nurse on 10/10/16, revealed she received a call from LPN #3 at 6:14 AM related to an incident involving SRNA #5 and called the Assistant Director of Nursing (ADON) who instructed her to remove SRNA #5 from resident care. Per the statement the House Charge Nurse arrived on the unit between 6:35 AM and 6:40 AM and removed SRNA #5 from resident care. Review of SRNA #5's Timecard, revealed SRNA #5 clocked in on 10/08/16 at 6:54 PM and clocked out on 10/09/16 at 6:54 AM. Interview with SRNA #5, on 10/27/16 at 3:15 PM, revealed she had gone into Resident #1's room to assist SRNA #6 in providing care to the resident, as the resident had removed his/her brief and needed incontinence care as well as the bed linens changed. SRNA #5 stated Resident #1 was making noises and she did not want the resident to wake up his/her roommate, and further stated it was by instinct that she covered Resident #1's mouth with her hand to try to quiet the resident. Continued interview with SRNA #5, revealed when SRNA #6 commented on her hand covering the resident's mouth, she immediately removed her hand. SRNA #5 stated she had training on Abuse by the facility and did not, at the time, think she was being abusive to the resident. SRNA #5 further stated she was devastated when she was informed by the House Charge Nurse that her actions could be considered Abusive. Interview with SRNA #6, on 10/31/16 at 8:55 AM, revealed on the morning of 10/09/16 at about 4:20 AM, she heard Resident #1 making noises and went to check on the resident. SRNA #6 stated she observed Resident #1 with his/her brief off and also observed the resident was incontinent of urine. SRNA #6 further stated she asked SRNA #5 to help with the care of the resident, then obtained linens and entered the room with SRNA #5 who commented she was afraid Resident #1 was going to wake up his/her roommate due to noises being made. Further interview, revealed she turned away to grab a sheet and when she turned back around, SRNA #5 had her hand over the resident's mouth and the resident was attempting to remove it. SRNA #6 stated she verbally corrected SRNA #5, who removed her hand and apologized. SRNA #6 further stated they both worked together to complete the care for Resident #1, then went up to the nurse's station. Per interview, she had training on Abuse and knew she was suppose to report any incidents immediately, but stated the nurse on duty at the time, Licensed Practical Nurse (LPN) #3, was busy talking to other staff members and SRNA #5 was also at the desk. SRNA #6 stated she did not want to say anything in front of SRNA #5, and she knew SRNA #5 was being pulled to another unit at 5:00 AM, and she wanted to wait until SRNA #5 had left the unit before reporting it to LPN #3. Continued interview revealed she reported the incident to LPN #3 at approximately 5:15 AM. SRNA #6 stated she had worked numerous times with SRNA #5 and had never seen her act inappropriately with any other residents. Further interview, revealed although SRNA #5 had her hand across the resident's mouth, her hand was not firmly in place, and once removed, she did not notice any reddened areas around the resident's mouth. SRNA #6 stated she did not think SRNA #5 was trying to harm the resident and added, she didn't think SRNA #5 knew any better. When asked why she did not contact the House Charge Nurse herself, SRNA #6 stated she was still new to the facility and was under the impression she needed to inform her immediate supervisor first. Interview with LPN #3, on 10/27/16 at 3:35 PM, revealed SRNA #6 informed her of the incident with Resident #1 which about 5:30 AM. LPN #3 further stated allegations of Abuse should be reported immediately, but she wanted to have her facts straight before contacting the House Charge Nurse regarding the incident with Resident #1. Interview with the House Charge Nurse, on 10/31/16 at 8:35 AM, revealed LPN #3 had informed her of the incident regarding SRNA #5 and Resident #1 at 6:14 AM. The House Charge Nurse stated she informed SRNA #6, she should have pulled LPN #3 aside and informed her of the incident immediately or contacted the House Charge Nurse directly herself. The House Charge Nurse further stated she informed LPN #3, she should have stopped her medication administration and contacted the House Charge Nurse immediately instead of trying to obtain more information. Further interview revealed SRNA #5 was very young, only nineteen (19) years old and of a different ethnic group. She stated she thought SRNA #5 was not aware of her actions being inappropriate and she was trying to quiet the resident down in the best interest of the roommate. \ Interview with the Staff Development Coordinator, on 10/27/16 at 4:35 PM, revealed all staff were trained on Abuse upon hire and at least annually. The Staff Development Coordinator stated the training was performed with lecture, copies of policies related to Abuse, as well as slides. Continued interview, revealed all staff must past a post test with one hundred percent (100 %) passing rate. Review of the facility's form Acknowledgement Of Zero Tolerance Resident Abuse Policy And The Duty To Report Abuse, stated staff was to immediately report suspected abuse once being aware, and it was not the staff's duty to determine if abuse occurred. Review of the personnel files, revealed SRNA #6 signed the form on 07/19/16, and LPN #3 signed the form on 05/04/15. Interview with the Assistant Director of Nursing (ADON), on 10/27/16 at 2:35 PM, revealed all staff received training on Abuse upon hire and at least annually. The ADON stated staff were instructed to report any allegations of Abuse immediately. She stated staff were to report allegations of abuse, or incidents which could be considered abuse, even if staff were not sure if Abuse occurred. The ADON further stated SRNA #6 should have reported the allegations immediately and should not have waited until SRNA #5 was off the unit. Continued interview revealed LPN #3 should have stopped whatever she was doing and immediately contacted the House Charge Nurse. Further interview with the ADON, revealed it was not acceptable to wait two (2) hours to report allegations of Abuse, and it was the facility's expectation that allegations of abuse be reported immediately. Interview with the Director of Nursing (DON), on 10/27/16 at 2:55 PM, revealed all staff was expected to report allegations of Abuse immediately. She stated from the investigation it was noted the incident occurred at 4:20 AM, and was not reported to LPN #3 until 5:00 AM, and then not reported to the House Charge Nurse until 6:14 AM. She stated SRNA #5 should have been immediately pulled from direct resident care after the incident was witnessed by SRNA #6 at 4:20 AM, but instead SRNA #5 continued to work until the House Charge Nurse was notified. The DON stated the facility has tried to instill into their staff that when a situation didn't feel right, they were to report the situation to administration, and administration would investigate the allegations. Interview with the Administrator, on 10/27/16 at 3:50 PM, revealed once SRNA #6 had finished providing care to Resident #1, she should have immediately notified the nurse on her unit, LPN #3 of the incident. The Administrator further stated, once LPN #3 was notified, she should have contacted the House Charge to start the Abuse investigation process. The Administrator stated it was not LPN #3's responsible to gather more facts prior to notifying the House Charge. Continued interview revealed it was his expectation for staff to follow the facility's policies and procedures and report all allegations of Abuse immediately for the protection of the residents.

Based on interview, record review and review of facility policy, it was determined the facility failed to provide notice regarding admission of a roommate for three (3) of thirty (30) sampled residents (Resident #7 #23, and #25). Interviews with Resident #7, #23, and #25 revealed they were not given prior notice when another resident was admitted to their rooms. The findings include: Review of the facility's Resident Admission Agreement, Section D, revealed when the facility assigned a resident to a double occupancy room, if there was an existing resident already occupying one (1) of the beds, that resident would be given as much notice as possible of the impending arrival of a new roommate. Review of the facility's policy titled Admission Process, revised 07/03/13, revealed no specific staff member was identified as being responsible for notifying an existing resident that they would be receiving a new roommate. 1. Review of Resident #7's medical record revealed the facility admitted the resident on 07/16/13 with [DIAGNOSES REDACTED]. Review of the Brief Interview For Mental Status (BIMS) score, dated 08/07/16, revealed the facility assessed Resident #7 to be cognitively intact with a score of fifteen (15) out of fifteen (15). Interview with Resident #7, on 10/04/16 at 11:15 AM, revealed the resident had received a new roommate earlier that day. Resident #7 denied being informed ahead of time by any facility staff that he/she would be receiving a roommate. Subsequent interview with Resident #7, on 10/06/16 at 1:51 PM, revealed it was a surprise when the new roommate arrived, and he had no prior knowledge of it. Resident #7 stated it would have been nice to have been informed before the roommate's arrival. Interview with the Social Worker for the unit where Resident #7 resided, on 10/05/16 at 1:47 PM, revealed she was not responsible for notifying existing residents when they would be receiving a newly admitted roommate. She stated she assumed it was the Unit Manager's responsibility. Interview with Unit Manager (UM) for Resident #7's unit, on 10/05/16 at 2:05 PM, revealed she was not aware of any facility staff members designated to inform residents that they were receiving a new roommate. The UM revealed direct care staff members would informally notify an existing resident they would be receiving a new roommate while setting up the bed and room for the new arrival. The UM stated notification of the existing resident was not routinely documented. 2. Review of Resident #23's medical record revealed the facility admitted the resident on 09/06/16 with [DIAGNOSES REDACTED]. Review of the BIMS score dated 09/12/16, revealed the facility assessed Resident #23 as cognitively intact with a score of thirteen (13) out of fifteen (15). Interview with Resident #23, on 10/06/16 at 9:15 AM, revealed he/she had received a roommate without having prior knowledge. Resident #23 stated he/she would have liked to have known ahead of time. 3. Review of the medical record revealed the facility admitted Resident #25 on 09/01/15 with [DIAGNOSES REDACTED]. On 07/25/16, the facility assessed the resident to have a BIMS score of fourteen (14), out of fifteen (15) which indicated Resident #25 was cognitively intact. Interview with Resident #25, on 10/06/16 at 11:20 AM, revealed he/she was not made aware he/she would be receiving a roommate until the resident was brought into the room. Resident #25 stated, it would have been nice to know ahead of time. Interview with the UM for Resident #25's unit, on 10/06/16 at 1:15 PM, revealed the unit was not usually aware of pending admissions until the day prior to admission. The UM stated if the unit had more than one (1) empty bed when she was informed of a new admission, she looked at various characteristics of the new arrival and tried to match those characteristics with current residents for compatibility. She further stated the Social Worker would then inform the current resident he/she would be getting a roommate. Further interview revealed if it was a holiday or weekend, the nurse would do the informing. Interview with the Social Worker on the unit where Resident #25 resided, on 10/06/16 at 2:10 PM, revealed Resident #25 could not remember if he/she was told about the roommate coming; however, stated she did remember informing Resident #25. She further stated it did appear she had failed to document the notification. Interview with the Admissions Coordinator, on 10/05/16 at 4:02 PM, revealed she did not know who was responsible for notifying an existing resident when they would be receiving a new roommate. Interview with the Director of Nursing (DON), on 10/06/16 at 2:30 PM, revealed it was her understanding the facility's Social Services Department was notifying existing residents when they would be getting a new roommate, prior to the roommate's arrival. The DON acknowledged she was not aware the facility's admission process policy did not designate a specific person who would be responsible for conducting the notification. The DON also acknowledged the facility's Admission Agreement did state a resident would be notified prior to receiving a new roommate. The DON stated, residents should be notified of a new roommate because it was their right, because it was their home, and because it was a matter of courtesy. She further stated she believed some of the facility's residents were not being notified prior to receiving a new roommate because the facility relied on an informal process of notification by direct care staff when the room was being prepared for a new admission. Continued interview revealed prior notification of the arrival of a roommate should occur, and it should be documented. Interview with the Administrator, on 10/06/16 at 2:45 PM, revealed the facility should have had someone designated to inform existing residents when they were getting a new roommate. The Administrator stated it had just never occurred to him to consider if the residents were informed ahead of time or if it was being documented. Per interview, the process would be changing.

Based on observation, interview, and review of facility policy, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection for two(2) of thirty (30) sampled residents (Resident #22 and #25) and seven (7) unsampled residents (Unsampled Residents A,B,C,D,E,F, and G). Observation of the lunch and supper meal service on 12/01/15, revealed staff failed to implement hand hygiene to prevent cross contamination while feeding more than one resident at a time during meal service. The findings include: Review of the facility's Guidelines for Hand Washing Policy, undated, revealed Handwashing was the single most important means of preventing the spread of infection. Per Policy, if the employee touched the resident's lips or tongue, the health care worker's hands should be washed. 1. Observation of the lunch meal service in the Jefferson Unit dining room on 12/01/15 at 12:25 PM, revealed State Registered Nursing Assistant (SRNA) #2 was observed to be feeding both Resident #25 and Unsampled Resident A their lunch. Resident #25 coughed and SRNA #2 placed a napkin to his/her mouth with her bare hands, until the resident stopped coughing. Continued observation revealed SRNA #2 then placed the napkin on the table and without washing or sanitizing her hands, preceded to feed Unsampled Resident A. Further observation, revealed SRNA #2 continued the same scenario two (2) more times, holding the napkin over Resident #25's mouth as he/she coughed, then placing the napkin back on the table, and continued feeding both residents. Telephone interview, on 12/03/15 at 4:00 PM with SRNA #2, revealed she was feeding Resident #25 and Unsampled Resident A when Resident #25 began coughing and she held the napkin up to the resident's mouth. She stated she did not think about the need to wash or sanitize her hands after this because she was only touching the napkin and not the resident's mouth. Continued interview, revealed after thinking about it, she should have washed her hands after Resident #25 coughed into his/her napkin. She stated, by not washing or sanitizing her hands after assisting Resident #25 with his/her cough, she could pass germs on to Unsampled Resident A and other residents. Interview, on 12/03/15 at 4:15 PM, with Registered Nurse (RN) #1/Nurse Manager of the Jefferson unit, revealed if any staff member touched a resident or self, they were to always wash/sanitize their hands before preceding to the next resident. Continued interview revealed this was a cross contamination and infection control concern. 2. Observation during supper meal service in the Washington Unit dining room on 12/01/15 at 5:30 PM, revealed Licensed Practical Nurse (LPN) #3 fed Resident #22, using the resident's paper napkin to wipe the resident's mouth. LPN #3 then without washing or sanitizing her hands, walked over and set up a meal tray for Unsampled Resident E, then picked up Unsampled Resident E's utensil and gave the resident a bite of food and a drink of milk. Further observation revealed LPN #3 then walked over and sat down between Unsampled Resident F and Resident #22. Without washing or sanitizing her hands, LPN #3 picked up Resident #22's utensil and started feeding the resident. After laying Resident #22's utensil down, LPN #3 picked up Unsampled Resident F's utensil and began feeding the resident, using the same hand in which she fed Resident #22. This scenario continued until both residents had finished their dinner meal. Interview, on 12/03/15 at 5:45 PM, with LPN #3, revealed she should have washed or sanitized her hands between feeding residents and especially after she had wiped Resident #22's mouth because this was a potential infection control risk. 3. Further observation during supper meal service on the Washington Unit dining room on 12/01/15 at 5:40 PM, revealed the Washington Unit Manager (UM) fed Unsampled Resident G a bite of food, gave the resident a drink from his/her cup, took the resident's paper napkin, wiped the resident's mouth, and placed the napkin on the resident's tray. The UM then walked over to Unsampled Resident B, and without washing or sanitizing her hands, picked up Unsampled Resident B's utensil, and gave the resident a bite of food, a drink from a cup, and wiped the resident's mouth using the resident's paper napkin. Continued observation revealed the UM preceded to feed Unsampled Resident G again without washing or sanitizing her hands. Further observation revealed she continued the same scenario multiple times placing the napkin back on each tray until both residents had completed their meals. Interview, on 12/03/15 at 2:30 PM, with the Washington UM, revealed she acknowledged she had not washed or sanitized her hands between feeding different residents their supper meal on 12/01/15, although she had contaminated her hands by wiping the resident's mouths. She further stated, feeding residents without sanitizing her hands between residents increased the risk for the spread of infection. 4. Continued observation of the Washington Unit dining room supper meal service on 12/01/15 at 5:48 PM, revealed SRNA#3 was observed sitting between Unsampled Resident C and Unsampled Resident D feeding them their supper meal. SRNA #3 fed Unsampled Resident D a bite of food, gave the resident a drink from his/her cup, took the resident's paper napkin, wiped the resident's mouth, and placed the napkin on the resident's tray. Then, without washing or sanitizing her hands, SRNA #3 picked up Unsampled Resident C's utensil and gave the resident a bite of food, a drink from a cup, and wiped the resident's mouth using the resident's paper napkin. This same scenario continued between Unsampled Resident C and Unsampled Resident D multiple times until both residents had completed their meals. Interview, on 12/03/15 at 6:10 PM, with SRNA #3, revealed she was aware she had not washed or sanitized her hands when feeding residents their supper meal on 12/01/15. She stated she should have washed or sanitized her hands between feeding residents to prevent spreading germs from resident to resident. Continued interview, revealed SRNA #3 was employed through an agency and had been trained on feeding and infection control risks by her agency. However, she stated she had been working at the facility off and on for over a year and the facility had not offered any in-service training or education related to infection control risks while feeding residents. Interview, on 12/03/15 at 11:50 AM, with the Infection Control Nurse/ Assistant Director of Nursing (ADON), revealed staff were to wash or sanitize their hands before and after any contact with residents to prevent the spread of infection. She further stated she needed to in-service all staff on the potential risk of the spread of infection during meals when hands were not sanitized or washed between residents. Continued interview revealed it was her expectation for all staff to follow the facility's handwashing policy. Interview, on 12/03/15 at 4:40 PM, with the Director of Nursing (DON), revealed it was her expectation for staff to sanitize their hands when their hands become contaminated from contact with residents.

Based on observation, interview, review of the Administrator's Job Description, and review of the Plan of Correction (POC) for the 12/03/15 Standard Survey, it was determined the facility's Administration failed to have an effective system in place to ensure proper storage of drugs and biologicals. The facility's Administration failed to ensure the facility maintained substantial compliance per the facility's POC as evidenced by a repeat deficiency from the standard survey, conducted on 12/03/15, at 42 CFR 483.60 Pharmacy Services (F431). Refer to F431. The findings include: Review of the facility's Kentucky Personnel Cabinet Position Description, date illegible, revealed the Administrator II was to manage all administrative programs, both medical and non-medical services and staff. The primary tasks included: directing operational and administrative support areas, overseeing and evaluating professional performance of all facility professionals, ensuring all department policies and procedures were developed, keeping current and following state and federal regulations, and overseeing the effective functioning of committees mandated by state and federal regulation. Review of the facility's, Medication and Controlled Substance Pass and Documentation Policy, revised 12/28/15, revealed residents would safely receive medications and controlled substances as ordered by the Medical Provider. Further review, revealed Insulin expired twenty-eight (28) days from the date opened, and staff was to always initial and date Insulin vials when opened. Per Policy, Monday through Friday on the 11:00 PM to 7:00 AM shift (night shift), licensed staff was to clean the Medication and Treatment Carts and check for outdated medications, treatments, and supplies. Observation on 02/10/16 of the Hall 2 Medication Cart on the Jefferson Unit, revealed two (2) expired vials of [MEDICATION NAME] 70/30 Insulin, one vial with an expiration date of 02/07/16 and the other vial with an expiration date of 02/09/16. Observation on 02/10/16 of the Hall 1 Treatment Cart on the Lincoln Unit revealed [MEDICATION NAME] Lotion 2.5% ,with a discard date of 07/31/15 and a bottle of [MEDICATION NAME] Acid Gel 2% with a discard date of 10/30/15. Observation on 02/10/16, of the Hall II Treatment Cart on the Lincoln Unit revealed (1) bottle of [MEDICATION NAME] 2% Creme Shampoo with a discard date of 06/16/15. Observation on 02/10/16, of Medication Cart One (1) on the Washington Unit revealed Dorzolamide HCI Solution 2% and one (1) [MEDICATION NAME] Inhaler, which were both opened without an open date or staff's initials on the boxes or the vials. Observation on 02/10/16 of Medication Cart One (1) on the Eisenhower Unit on revealed Insulin [MEDICATION NAME] Solution 100 UNIT/Milliliter, [MEDICATION NAME] P Solution, [MEDICATION NAME] Propionate HFA Aerosol and [MEDICATION NAME] Inhaler which were all opened without an open date or staff initials on the boxes or the vials. Also, observation on 02/10/16 of Medication Cart two (2) on the Eisenhower Unit, revealed [MEDICATION NAME] Ophthalmic Eye Drops without an open date or staff initials on the box or vial. Review of the facility's Plan of Correction (POC) for the Recertification Survey on 12/03/15 with a compliance date of 01/17/16, revealed all licensed nursing staff and Kentucky Medication Aides were educated related to the facility's Medication and Controlled Substance Pass and Documentation Policy, labeling Insulin, and checking treatment carts daily for expired biologicals including bandages and supplies. Per the POC, the facility administered post tests for labeling insulin and checking treatment carts for expired biologicals with one hundred percent (100%) accuracy. Review of the facility's Inservice Training binders, on 02/12/16, revealed staff signatures on the inservice training forms indicating all training was completed by 01/16/16. Review of the facility's Post Tests revealed staff had completed the tests with no deficiencies. Further review of the facility's Inservice Training binders revealed the staff was inserviced on the facility's Medication and Controlled Substance Pass and Documentation Policy. Interview with Licensed Practical Nurse (LPN) #8, on 02/10/16 at 5:40 PM, revealed she had recently received in-service training regarding the dating of Insulin vials and checking for expired Insulins in the Medication Cart and knew to discard out of date medication. Interview with LPN #10, on 02/11/16 at 3:25 PM, revealed she had recently attended an in-service related to opening and dating Insulin and was aware of the need to check medications for expiration dates prior to administration. Interview with Registered Nurse (RN) #5/Charge Nurse, on 02/10/16 at 11:20 AM, revealed the nurses had received an inservice shortly after the State Survey in December 2015, related to proper dating and labeling of medications, dressing supplies, and biologics and also related to expired medication disposal and the night shift nurse was to check medication and treatment carts nightly to ensure compliance. Interview on 2/10/16 at 11:31 AM, with LPN #6, revealed staff had been inserviced related to removing expired medications and biologicals from the medication and treatment carts, and were thoroughly checking the treatment carts but the shampoo was not being checked which was a breakdown in the system. Interview with LPN #9/Agency Staff Nurse, on 02/10/16 at 11:45 AM, revealed she had worked at this facility one (1) to two (2) shifts per week since December 2015. She further stated, she was aware all medications and biologicals needed to be initialed and dated when opened and was aware of the need to check for expired dates and discard when necessary. Interview with RN/#6 on 02/10/16 at 11:50 AM, revealed there was an inservice sometime in December 2015 about compliance of dating and initialing medications and biologics when opened, and discarding the expired medications. She further stated, although the medication carts and treatment carts were checked on night shift, it was the responsibility of all nurses to check medications and biologics on a daily basis. Interview on 2/11/16 at 2:14 PM, with LPN #2, revealed staff had been educated through inservices and written tests in December 2015 and January 2016 regarding expired medications/biologicals disposal. However, LPN #2 stated she was not aware shampoos were biologicals. Interview with the Director of Nursing/Director of Quality Assurance (QA), on 02/11/16 at 2:45 PM, revealed Nursing Management was responsible for the education given during the in-services and the audits were performed of the Medication and Treatment carts to ensure compliance with the facility's POC. She stated staff was educated on facility policy related to checking the Medication and Treatment carts to look for outdated medications, treatments and supplies, but the focus was mostly related to checking for expired Insulins and bandages because this was a concern during the Standard 12/03/15 Survey. Interview with the Administrator, on 02/11/16 at 4:00 PM, revealed staff was re-educated as stated in the POC, but he felt the process needed time to work as they had not yet had a meeting to discuss the concerns noted with the auditing and what education may need to be re-addressed.

Based on observation, interview, review of the facility's Policy and Plan of Correction (POC) for the Standard [DATE] survey, it was determined the facility failed to maintain a Quality Assessment and Assurance (QA) Program that developed and implemented effective plans of action to correct quality deficiencies. This was evidenced by the repeat deficiency from the Standard survey, conducted on [DATE], related to the facility's failure to ensure proper storage of drugs and biologicals at 42 CFR 483.60 Pharmacy Services (F-431). Refer to F431. The findings include: Review of the facility's, Administrative Policy Manual reviewed [DATE], under the section titled Quality Management System, revealed the facility supported a quality management system led by the Administrator, reinforcing participating management culture and focused on achieving the following goals: a system which validates a comprehensive set of interdisciplinary and interdepartmental long term care health and lifestyle outcomes's for the Veteran Residents, a system which validates organizational outcomes for the employees, and an efficient and effective system for collection, analysis, and action planning of quality management data. Further review revealed this data was to reflect performance across all organizational levels and departments. Review of the facility's Plan of Correction (POC) for the Standard survey completed on [DATE], with a compliance date of [DATE], revealed audits would be performed weekly by the Nurse Managers or Charge Nurses to ensure opened vials of Regular Insulin were dated correctly and treatments and supplies were not expired for each medication cart and each treatment cart. Per the POC, there would be a checklist audit performed weekly for one (1) month, every other week for one (1) month, then once for one (1) month which would be submitted to the Assistant Directors of Nursing for verification of compliance and then forwarded to the Director of Nursing (DON) for review. Review of the facility's audits performed revealed the facility implemented the POC; however, observation during this revisit survey revealed monitoring was ineffective in ensuring overall compliance with labeling and storage of medications and biologicals. Observation on [DATE] during this Revisit Survey revealed the following: Observation of Medication Cart One (1) on the Eisenhower Unit revealed Insulin [MEDICATION NAME] Solution 100 UNIT/Milliliter, [MEDICATION NAME] P Solution and [MEDICATION NAME] Propionate HFA Aerosol which were opened without an open date or staff initials on the boxes or vials. Also, observation of Medication Cart Two (2) on the Eisenhower Unit revealed [MEDICATION NAME] Ophthalmic Eye Drops without an open date or staff initials on the box or vial. Interview with the Eisenhower Unit Manager, on [DATE] at 1:40 PM, revealed she had been performing the weekly audits but their focus was on the Insulin and bandages instead of the whole medication cart. Observation of Medication Cart One (1) on the Washington Unit, revealed Dorzolamide HCI Solution 2%, and one (1) [MEDICATION NAME] Inhaler, which were both opened without an open date or staff initials on the boxes or vials. Interview with the Washington Unit Manager, on [DATE] at 2:00 PM, revealed she had been performing the audits weekly as specified in the POC, but this did not include checking all medications since only Insulin was specifically identified in the facility's POC to be audited. The Jefferson Unit Hall Two (2) Medication Cart had two (2) vials of [MEDICATION NAME] Insulin and one (1) with an expiration date of [DATE] and the other with an expiration date of [DATE]. Interview with the Jefferson Unit Manager, on [DATE] at 2:10 PM, revealed she had been performing the weekly audits per the POC and had checked the medication cart on [DATE] and was scheduled to check the medication cart again on [DATE]. She stated the audit failed due to being too specific in looking for mainly Insulin and bandages. Observation of the Hall One (1) Treatment Cart on the Lincoln Unit revealed a bottle of [MEDICATION NAME] Lotion 2.5% with a discard date of [DATE]. Further observation of the Hall One (1) Treatment Cart on the Lincoln Unit, revealed a bottle of [MEDICATION NAME] Acid Gel 2% in the Treatment cart with a discard date of [DATE]. Interview with the Lincoln Unit Manager, on [DATE] at 2:30 PM, revealed she had been performing the audits every week but stated she had not considered medicated shampoo as a biological. Interview with the Director of Nursing/Director of QA, on [DATE] at 2:45 PM, revealed Nursing Management was responsible for the education given during the in-services as well as auditing the Medication and Treatment carts for compliance with the facility's POC. She stated the audit system failed due to staff being too focused on the Insulin and Bandages and not focusing as much on the other medications and biologicals. She further stated, she felt staff was monitoring for expired medication but not looking ahead and removing items which were going to expire prior to the next audit date. Interview with the Administrator, on [DATE] at 4:00 PM, revealed staff was re-educated and audits were being performed as stated in the POC. The Administrator stated the facility had not met to discuss the results of the audits prior to the Revisit Survey. Continued interview, revealed he did not think the audits were accurate but was unsure if having additional audits per week or changing the scope of the audits would be effective in obtaining compliance related to the deficiency cited. The Administrator stated the audits failed, and the process needed time to work.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of thirty (30) sampled residents (Resident #4). Resident #4 sustained a fall on 11/15/15 due to standing up and then sitting back down and missing his/her wheelchair. Although the Post Fall Huddle Meeting (brief meeting after a fall that includes staff caring for the resident to identify the root cause of the fall and to implement further interventions to prevent falls) identified the need for staff to supervise the resident while he/she was up in the wheelchair, there was no documented evidence the intervention was implemented or that staff caring for the resident were made aware of this intervention. Resident #4 sustained another fall on 11/20/15 which was unwitnessed, when the resident again stood from the wheelchair and fell to the floor while not being supervised, experiencing a skin tear to the right elbow. The findings include: Review of the facility's policy, titled Fall Prevention Management, revised 11/05/09, revealed members of the Interdisciplinary Team (IDT) would be responsible for assessing, planning, and implementing strategies for the prevention of resident falls and re-evaluating the interventions if falls occur. Further review of the policy revealed staff would be responsible for creating a safe environment for the residents to prevent falls. Review of Resident #4's clinical record revealed the facility admitted the resident on 10/04/12 with [DIAGNOSES REDACTED]. Review of the Comprehensive Plan of Care (CPC) initiated 05/13/15, revealed the resident was at high risk for falls related to gait/balance problem, Urinary Retention, recent eye surgery for [REDACTED]. The CPC goal stated the resident would not sustain serious injury. There was several interventions including; call light in reach, frequent checks between 11:00 AM and 3:00 PM, ensure walker was in reach, ensure appropriate footwear such as shoes or non skid socks, and assist to toilet at bedtime. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 09/28/15, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) which indicated the resident had moderate cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as requiring extensive assist of two (2) persons for bed mobility and transfers, and as requiring limited assist of one (1) person for ambulation. Continued review of the MDS, revealed the facility assessed the resident as having two (2) falls with injury, two (2) falls with no injury and no falls with major injury since admission/entry or reentry or prior assessment. Review of Resident #4's Fall Risk Assessment, dated 10/01/15, revealed the resident was assessed as being at High Risk for falls related to intermittent confusion, history of three (3) or more falls, was chairbound and or needed assist with elimination, poor vision, balance problem, unstable when making turns, required an assistive device, and predisposing diseases. Review of the facility's Fall Incident Report/Quality Monitor, dated 11/15/15, revealed Resident #4 sustained a fall on 11/15/15 at 6:00 AM. Continued review revealed the resident was by the nurses station and a co-resident informed staff that Resident #4 went to sit back down in his/her wheelchair and sat on the floor. Per the Incident Report, there was no visible injuries and no complaints of pain. Further review of the Incident Report revealed the new intervention to prevent further falls was to place roll back brakes on the wheelchair. Review of the Post Fall Huddle Note, dated 11/15/15, revealed staff suggested not to leave the resident unattended while up in his/her wheelchair. However, there was no documented evidence this intervention was added to the CPC in an attempt to prevent further falls. Review of the facility's Fall Incident Report/Quality Monitor, dated 11/20/15, revealed Resident #4 sustained another fall on 11/20/15 at 9:40 AM in the hallway. Continued review revealed the resident was found on the floor lying on his/her right side, the fall was unwitnessed and the resident was unable to verbalize why he/she fell . Further review revealed Resident #4 experienced a skin tear to the right elbow from the fall. Per the Incident Report the foot rest was on the wheelchair and may have contributed to the fall when the resident stood to transfer, and staff was educated to remove the resident's foot pedals when on the unit and to place them in a bag. Interview with State Registered Nurse Aide (SRNA) #5, on 12/03/15 at 3:35 PM, revealed she was assigned to Resident #4 often and the resident was a fall risk. Continued interview with SRNA #5 revealed Resident #4 constantly stood up in his/her chair and would not sit down. SRNA #5 revealed she was not told to keep an eye on the resident while he/she was up in the chair, stating it was impossible, to keep an eye on the resident when staff have to assist other residents who were two (2) assist. Interview with Licensed Practical Nurse (LPN) #4, on 12/03/15 at 4:32 PM, revealed she was assigned to Resident #4 often. LPN #4 revealed the resident was often non-compliant and would sometimes attempt to stand up unassisted from his/her wheelchair. Continued interview, revealed it was difficult to see Resident #4 visually at all times. She reviewed the resident's CPC and stated the CPC did not address providing supervision for the resident while up in his/her wheelchair. However, she stated this would be a good intervention to add to the CPC because there was a lot of agency workers assigned to the residents and they were unfamiliar with the residents behaviors. Interview with the MDS Coordinator, on 12/03/15 at 5:09 PM, revealed when a resident fell , she would review the Incident Report, review the time of the resident's fall, and would review all of the interventions. Continued interview revealed the Post Fall Huddle, interventions were new interventions to be put in place after a fall. Further interview revealed the resident's CPC was not updated to indicate the resident would be supervised while up in his/her wheelchair, but stated that should have been a given. Interview with the Director of Nursing (DON) and Resident #4's Unit Manager, on 12/03/15 at 6:10 PM, revealed when there was a fall, the staff assigned and/or involved on the unit would get together within fifteen (15) minutes post fall to talk about possible contributing factors to the fall and come up with a new intervention to prevent further falls. The DON revealed, when staff added the intervention to supervise Resident #4 while up in his/her wheelchair on the Post Fall Huddle form, dated 11/15/15, this intervention should have been added to his/her care plan in order to implement additional supervision. She further revealed each fall was also discussed in the Interdisciplinary Team Meeting (IDT) where they reviewed all information related to the fall including the Incident Report, and Post Fall Huddle Notes; however, the intervention for Resident #4 for supervision while in the wheelchair was missed.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Plan of Care (CPC) was revised for one (1) of thirty (30) sampled residents (Resident #4). Resident #4 fell on [DATE] due to standing up and then sitting back down and missing his/her wheelchair. The Post Fall Huddle Meeting (brief meeting after a fall that includes staff caring for the resident to identify the root cause of the fall and to implement further approaches to prevent falls) identified the need for staff to supervise the resident while he/she was up in the wheelchair; however, there was no documented evidence the CPC was revised related to this approach. On 11/20/15, Resident #4 fell again when the resident again stood from the wheelchair and fell to the floor while not being supervised, experiencing a skin tear to the right elbow. The findings include: Review of the facility Care Planning-Interdisciplinary Team Policy, dated 05/21/15, revealed Assessments of residents were ongoing and Care Plans were revised as information about the resident and the resident's condition changed. The Care Planning /Interdisciplinary Team was responsible for the review and updating of Care Plans when there was a significant change in the resident's condition, when the resident was readmitted to the facility from a hospital stay, at least quarterly, and when the desired outcome was not met. Review of Resident #4's medical record revealed the facility admitted the resident on 10/04/12 with [DIAGNOSES REDACTED]. Review of the Comprehensive Plan of Care (CPC) initiated 05/13/15, revealed the resident was at high risk for falls related to gait/balance problem, [MEDICAL CONDITION], recent eye surgery for [REDACTED]. The goal stated the resident would not sustain serious injury. There was several approaches listed including; call light in reach, frequent checks between 11:00 AM and 3:00 PM, ensure walker was in reach, ensure appropriate footwear such as shoes or non skid socks, and assist to toilet at bedtime. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 09/28/15, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) which indicated the resident had moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) persons for bed mobility and transfers, and as requiring limited assist of one (1) person for ambulation. Continued review revealed the facility assessed the resident as having two (2) falls with injury, two (2) falls with no injury and no falls with major injury since admission/entry or reentry or prior assessment. Review of the resident's Fall Risk Assessment, dated 10/01/15, revealed Resident #4 was assessed as being at High Risk for falls related to intermittent confusion, history of three (3) or more falls, was chairbound and or needed assist with elimination, poor vision, balance problem, unstable when making turns, required an assistive device, and predisposing diseases. Review of the Fall Incident Report/Quality Monitor, dated 11/15/15, revealed Resident #4 sustained a fall on 11/15/15 at 6:00 AM. Further review revealed the resident was by the nurses station and a co-resident informed staff that Resident #4 went to sit back down in his/her wheelchair and sat on the floor. According to the Incident Report, there was no visible injuries and no complaints of pain. Per the Incident Report, the new approach to prevent further falls was to place roll back brakes on the wheelchair. Review of the Post Fall Huddle Note, dated 11/15/15, revealed staff suggested not to leave Resident #4 unattended while up in his/her wheelchair. However, there was no documented evidence the CPC was revised with this intervention in an attempt to prevent further falls. Review of the Fall Incident Report/Quality Monitor, dated 11/20/15, revealed Resident #4 sustained another fall on 11/20/15 at 9:40 AM in the hallway. Per the Incident Report, the resident was found on the floor lying on his/her right side, the fall was unwitnessed and the resident was unable to verbalize why he/she fell . Continued review revealed Resident #4 experienced a skin tear to the right elbow from the fall. According to the Incident Report the foot rest was on the wheelchair and may have contributed to the fall when the resident stood to transfer, and staff was educated to remove the resident's foot pedals when on the unit and to place them in a bag. Interview with State Registered Nurse Aide (SRNA) #5, on 12/03/15 at 3:35 PM, revealed she was assigned to Resident #4 often and was aware the resident was a fall risk. Further interview with SRNA #5 revealed Resident #4 constantly stood up in his/her chair and would not sit down. SRNA #5 stated, she was not told to keep an eye on the resident while he/she was up in the chair, stating it was impossible, to keep an eye on the resident when staff have to assist other residents who were two (2) assist. Interview with Licensed Practical Nurse (LPN) #4, on 12/03/15 at 4:32 PM, revealed she was often assigned to Resident #4. LPN #4 stated the resident was often non-compliant and would sometimes attempt to stand up unassisted from his/her wheelchair. Further interview, revealed it was difficult to see Resident #4 visually at all times. LPN #4 reviewed the resident's CPC and stated the CPC did not address providing supervision for the resident while up in his/her wheelchair. However, LPN #4 revealed this would be a good approach to add to the CPC because there was a lot of agency workers assigned to the residents and they were unfamiliar with the residents behaviors. Interview with the MDS Coordinator, on 12/03/15 at 5:09 PM, revealed when a resident fell , she would review the Incident Report, review the time of the resident's fall, and would review all of the interventions to ensure they were adequate. Further interview revealed the Post Fall Huddle, interventions were new interventions which were placed after a fall. The MDS Coordinator revealed the resident's CPC was not revised to indicate the resident would be supervised while up in his/her wheelchair, but stated that should have been a given. Interview with the Director of Nursing (DON) and Resident #4's Unit Manager, on 12/03/15 at 6:10 PM, revealed when there was a fall, the staff assigned and staff involved on the unit would get together within fifteen (15) minutes post fall to talk about the possible contributing factors to the fall and attempt to come up with a new approach to prevent further falls. The DON stated, when staff added the intervention to supervise Resident #4 while up in his/her wheelchair on the Post Fall Huddle form, dated 11/15/15, the CPC should have been revised with this intervention in order to implement additional supervision. Continued interview with the DON and Unit Manager revealed the CPC was important because it was a road map to assist with the care of the resident.